Spreading Good Practice: Sarah Fraser

Managing the legacy of your project

2012-05-29T08:45:00.000+01:00

Ending a project is as chaotic an affair as the start up. After the flurry of the beginning and the more measured stage of making progress, we are then faced with wrapping things up. So what do you want to have as the legacy from your project?

Mostly it's all about figuring out how to keep the website going, debating where to put the useful resources that have been developed, and managing the process of celebrating results and saying goodbye to project teams. But is this enough?

Project outcomes are good - and always worth advertising.

But what is your legacy? By legacy I mean the long term, sustainable, "thing" that has resulted form your program. Sometimes this isn't seen clearly until years later. There's an excellent paper I commend you to read which covers the difference between people, process and product legacies. I particularly like the "reuse" concept.

An introduction to Activity Theory

2012-05-24T14:33:00.000+01:00

I'm finding Activity Theory very useful for thinking about large scale change. Traditional quality improvement, implementation science, dissemination science, organisational development and the like, are all useful. However, every theory has its limitations and although Activity Theory isn't perfect, it does provide some thought-provoking challenges.

There's a good 9 minute introduction, though you do need to be in a quiet place and be concentrating...

Please. No. More. Research. We. Need. Action.

2012-05-21T10:22:00.000+01:00

Now before you send me a complaint, I'll start by saying I do believe that research is a good thing. However, we can have too much of a good thing.

The February Editorial in Implementation Science pitches the question as to whether we need a scientific study for research on how to improve healthcare. Here are my thoughts:

I am not convinced we need any more "what" when it comes to improvement; we are drowning in good practice, guidelines etc.
When it comes to the how" then I'm more interested in getting people to the "do" stage of making changes, than in spending more time pondering how best to go about it. By doing, the people learn.
Researchers, and I'm a closet researcher so I know, tend to be separated from the real world in time and space.
I suspect we have 80% of the "how" that we need to improve healthcare. What we lack are the people within healthcare who are sufficiently motivated to make the changes - or get out of the way of people who are motivated to make the change

Implement Sci. 2012 Feb 29;7:10.
Does the world need a scientific society for research on how to improve healthcare?
Wensing M, Grimshaw JM, Eccles MP.

Sustainabilty of QI results; we're not sure how to make it happen

2012-05-18T10:13:00.000+01:00

I love systematic reviews. Someone else does the hard work of synthesising the literature and pointing out the strengths and weaknesses.

If you come across anyone purporting to tell you how you can sustain the results of your improvement work, then send them this paper. Basically, we're not sure how sustainability happens other than it is a complex matter, and not one for a checklist or one day seminar. What I like about this systematic review is it points out the complexity, the system dynamics issues and the need for published work to identify the contextual factors in the sustainability (or not) or results.

Excellent work here by the authors.
Thank you.

Implement Sci. 2012 Mar 14;7(1):17. [Epub ahead of print]
The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research.
Wiltsey Stirman S, Kimberly J, Cook N, Calloway A, Castro F, Charns M.

Partial Abstract

"RESULTS:
Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves.
CONCLUSIONS:
Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment."

How is evidence being used?

2012-05-17T10:05:00.000+01:00

Having moaned in this blog a few days ago about people not searching for evidence, I see a small group have set out a protocol to examine just how managers and professionals access the evidence.

I hope they will also do the negative study - those who are not accessing the evidence...

Implement Sci. 2012 Mar 21;7(1):22. [Epub ahead of print]
Making sense of evidence in management decisions: the role of research-based knowledge on innovation adoption and implementation in healthcare. Study protocol.
Kyratsis Y, Ahmad R, Holmes AH.

"Abstract
BACKGROUND:
We know that patient care can be improved by implementing evidence-based innovations and applying research findings linked to good practice. Successfully implementing innovations in complex organisations, such as the UK’s National Health Service (NHS), is often challenging as multiple contextual dynamics mediate the process. Research studies have explored the challenges of introducing innovations into healthcare settings and have contributed to a better understanding of why potentially useful innovations are not always implemented in practice, even if backed by strong evidence. Mediating factors include health policy and health system influences, organisational factors, and individual and professional attitudes, including decision makers’ perceptions of innovation evidence. There has been limited research on how different forms of evidence are accessed and utilised by organisational decision makers during innovation adoption. We also know little about how diverse healthcare professionals (clinicians, administrators) make sense of evidence and how this collective sensemaking mediates the uptake of innovations.
METHODS:
The study will involve nine comparative-case study sites of acute care organisations grouped into three regional clusters across England. Each of the purposefully selected sites represents a variety of trust types and organisational contexts. We will use qualitative methods, in-depth interviews, observation of key meetings, and systematic analysis of relevant secondary data to understand the rationale and challenges involved in sourcing and utilising innovation evidence in the empirical setting of infection prevention and control. We will use theories of innovation adoption and sensemaking in organisations to interpret the data. The research will provide lessons for the uptake and continuous use of innovations in the English and international health systems.
DISCUSSION:
Unlike most innovation studies, which involve single-level analysis, our study will explore the innovation-adoption process at multiple embedded levels: micro (individual), meso (organisational), and macro (interorganisational). By comparing and contrasting across the nine sites, each with different organisational contexts, local networks, leadership styles, and different innovations considered for adoption, the findings of the study will have wide relevance. The research will produce actionable findings responding to the political and economic need for healthcare organisations to be innovation-ready."

2012-05-14T10:02:00.000+01:00

Dissemination Science. OK, that's a useful way of thinking about it.
A framework for training competency in implementation and dissemination science - now that sounds very useful.

Acad Med. 2012 Mar;87(3):271-8.A framework for training health professionals in implementation and dissemination science.Gonzales R, Handley MA, Ackerman S, Oʼsullivan PS.

This is their abstract

"The authors describe a conceptual framework for implementation and dissemination science (IDS) and propose competencies for IDS training. Their framework is designed to facilitate the application of theories and methods from the distinct domains of clinical disciplines (e.g., medicine, public health), population sciences (e.g., biostatistics, epidemiology), and translational disciplines (e.g., social and behavioral sciences, business administration education). They explore three principles that guided the development of their conceptual framework: Behavior change among organizations and/or individuals (providers, patients) is inherent in the translation process; engagement of stakeholder organizations, health care delivery systems, and individuals is imperative to achieve effective translation and sustained improvements; and IDS research is iterative, benefiting from cycles and collaborative, bidirectional relationships. The authors propose seven domains for IDS training-team science, context identification, literature identification and assessment, community engagement, intervention design and research implementation, evaluation of effect of translational activity, behavioral change communication strategies-and define 12 IDS training competencies within these domains. As a model, they describe specific courses introduced at the University of California, San Francisco, which they designed to develop these competencies. The authors encourage other training programs and institutions to use or adapt the design principles, conceptual framework, and proposed competencies to evaluate their current IDS training needs and to support new program development."

What is disruptive innovation?

2012-05-10T14:23:00.000+01:00

A disruptive innovation is not a breakthrough innovation that has taken something and made better.It is an event or product which transforms the entire notion of the experience or product.
We would like disruptive innovation in healthcare, but mostly we do breakthrough innovation - at best.

Listen (<5mins) to the definition of disruptive innovation from the man himself, courtesy of Harvard Business Review (HBR)

Is Activity Theory useful for large scale change?

2012-05-08T09:52:00.000+01:00

There's no shortage of theories and models for how good practice can be "spread". I'm part fo the problem by generating some of them.... I've recently become curious about the use of Activity Theory as a means of large scale change in healthcare settings. It's a bit of an eclectic theory from the social sciences - but then, PDSA cycles were once an eclectic Japanese theory.

Wikipedia has a good intro. Basically, the benefits of Activity Theory is it combines all system levels into one model of change - from individual through to policy. And I like that.

Greg, Entwistle and Beech have a new paper which considers how AT can be applied usefully in healthcare.

Soc Sci Med. 2012 Feb;74(3):305-12. Epub 2011 Mar 1.
Addressing complex healthcare problems in diverse settings: Insights from activity theory.
This is their abstract: "In the UK, approaches to policy implementation, service improvement and quality assurance treat policy, management and clinical care as separate, hierarchical domains. They are often based on the central knowledge transfer (KT) theory idea that best practice solutions to complex problems can be identified and 'rolled out' across organisations. When the designated 'best practice' is not implemented, this is interpreted as local - particularly management - failure. Remedial actions include reiterating policy aims and tightening performance management of solution implementation, frequently to no avail. We propose activity theory (AT) as an alternative approach to identifying and understanding the challenges of addressing complex healthcare problems across diverse settings. AT challenges the KT conceptual separations between levels of policy, management and clinical care. It does not regard knowledge and practice as separable, and does not understand them in the commodified way that has typified some versions of KT theory. Instead, AT focuses on "objects of activity" which can be contested. It sees new practice as emerging from contradiction and understands knowledge and practice as fundamentally entwined, not separate. From an AT perspective, there can be no single best practice. The contributions of AT are that it enables us to understand the dynamics of knowledge-practice in activities rather than between levels. It shows how efforts to reduce variation from best practice may paradoxically remove a key source of practice improvement. After explaining the principles of AT we illustrate its explanatory potential through an ethnographic study of primary healthcare teams responding to a policy aim of reducing inappropriate hospital admissions of older people by the 'best practice' of rapid response teams."

Why don't we search for evidence?

2012-05-04T09:34:00.000+01:00

So I'm perplexed.

I've spent years listening to leaders at all levels - from unit, to department, to organisation, to region, to National - all say they want "other people" (usually those "beneath" them) to adopt existing good practices.

That's all good and well.

But when I press these leaders on what efforts they've made to check the literature, search for existing guidelines or consider the experience of people similar to themselves - they all look at me blankly. One recently told me that "that sort of thing is for the people who need to improve, not me. They need to adopt guidelines." When I pressed him about the opportunity he has to learn from others in the design of his large scale intervention, he replied "We're different."

I shall invest a new piece of equipment - a mirror.

Self Management Support Tools and Resources

2012-05-02T08:23:00.000+01:00

Hoorah! We're finally moving from what often feels the patronising approach of "empowering patients" to finding ways to truly be partners in their care process. There are multiple projects and programs round the world which demonstrate what can be done. I've put together a list of resources which you may find useful.

1. My favourite are from The Health Foundation. Their package is comprehensive and includes materials for training staff so is excellent for getting the message out there in a practical way. They've also got resources for improving patient skills.

2. The Institute for Improvement has a short guide which is useful if you want to check what you may need to do to get some benefits.

3. There's an excellent write up about the long term conditions collaborative in Scotland where they identify the top high impact changes you can make.

4. Selfmanagement,.co.uk also has resources and it's one of the few places I've seen where there's information on relevant published literature. In fact, the more I look at this website, the more I feel it is perhaps the most comprehensive and useful...

Do you have any favourite self management support resource links you'd like to share? Please comment below and I'll add to this blog.

Do you share your experiences?

2012-05-01T10:37:00.000+01:00

I recently watched a three year old coming to terms with her one year old brother's need to hold a toy that until recently she thought belonged to her. Sharing - it doesn't necessarily get any easier. But for some people, it is automatic. Dr Michael Bergstrom from SKL, Sweden, sent me a one page summary and a pictures of the top 10 slides (in his opinion) from the Paris Euroforum.

Just a perfect example - of sharing.

Is the role of an organisational champion effective?

2012-04-30T09:27:00.000+01:00

The label "champion" is a complex one to wear and one which I've been a bit cautious about recommending anyone use. In the UK, it's been common to identify that enthusiastic doctor or nurse, label them the champion for the work and then expect them to get on and lead the changes. Sometimes this works, and sometimes it doesn't.

There's a really interesting paper published (by Hendy & Barlow, Imperial College, London) which examines the role of the champion and their effectiveness in one program in the UK. I like this research because it is lengthy (three years is a long time) and ethnographic. Their bottom line, it seems, is that it's good to be a champion in your own patch, but as soon as you're expected to deliver your champion role outside your regular context, then the effectiveness drops off. This is instinctively logical but all the same it's good to see some research on the topic.

Soc Sci Med. 2012 Feb;74(3):348-55. Epub 2011 Mar 1.
The role of the organizational champion in achieving health system change.

How does organisational context impact spread and adoption

2012-04-27T09:19:00.000+01:00

Those who know me, know I am critical of the continued use of Roger's Diffusion Curve as a means of telling people how and how to plan for the spread and adoption of good practice. If you read Roger's work in depth you will understand its limitations.

One of these is the lack of attention to context. It's fairly obvious to anyone involved in spread and adoption of good practice that leadership, organisational culture and readiness to change etc. are all important in the process. The problem is, although many models and frameworks are drawn up to show how context is important - which is an excellent first step - there is a shortage of published work on the topic.

A key problem is that those who publish ignore the contextual factors. A recent review paper by Emmens, Weiner & Fernandez looks at this issue.

Health Educ Behav. 2012 Feb;39(1):87-105. Epub 2011 Jul 1.
Systems antecedents for dissemination and implementation: a review and analysis of measures

WHO Patient Safety Curriculum Guide

2012-04-25T09:09:00.000+01:00

More great resources from the World Health Organisation. To be frank - this curriculum guide is the most comprehensive set of teaching resources on patient safety that I've come across in a decade. It has been developed by multi-professional groups so avoids the biases that so often occur when courses are developed by a single organisation. Whilst it's aimed at integrating patient safety into educational curricula, there's no reason why you can't use this within your own organisational setting.

You can access the multi-professional guide here. If you would like the teaching slides for each of the 11 topics then you can download them here, where you will also find background and evaluation information.

And unless I'n missing something - these are free to use - so no there is no excuse in wasting time creating, developing, designing, discussing how to educate and train staff in patient safety. Nor should you be paying anyone to do the creating, designing, developing etc.

Well done WHO!

International Profiles of Healthcare Systems

2012-04-23T08:55:00.000+01:00

A fascinating comparison of healthcare systems is available for The Common Wealth Fund.

Some highlights:

Healthcare system financing and coverage: there's a table that shows how 14 countries finance healthcare (I thought the NHS was complicated in England, but I see it really is quite simple when it comes to financing it.)
Selective system indicators: this is where you get to see how funding, population, numbers of physicians etc link to chronic care management, avoidable deaths etc. It's all riveting reading but I'm impressed by England's capacity for quality in Primary Care.
There is a chapter on each of the fourteen countries: Australia, Canada, Denmark, England, France, Germany, Italy, Japan, the Netherlands, Norway, Sweden, Switzerland and the USA

There's nothing like a bit of comparison to place both positive and negative aspects of our healthcare systems in context. I thoroughly recommend at least browsing the tables, if not reading the whole report.

Why one to many is not a large scale change strategy

2012-04-19T14:07:00.000+01:00

Large scale change is about the numbers. If part fo your strategy for large scale change is to develop or use networks to communicate your message then you need to understand the mathematics of networks.

If you don't know about Sarnoff's Law, Metcalfe's Law and Reed's law - then watch this video, which if nothing else, explains why broadcasting messages is low impact. It's 10 minutes long but hang in there - it's the best explanation I've heard for a long time.

The numbers:
Sarnoff: 1 message to 20 people: network score of 20

Metcalfe: Email and telephones connect humans and help small groups form: because everyone can connect to everyone, the potential is 20 x 20, meaning a network score of 400.

Reed: the value of the network is exponential in social networking, going beyond the establishing communities.. So it's 2 to the power of 20 which is 1,000,000.

Reed's Law is about scale.
Social networking matters.

Run Charts: How to create and interpret

2012-03-02T10:45:00.001Z

Managing data in an improvement project often feels like it is some magical craft, with spells, secrets and strange ingredients. But this isn't true. A run chart is the most basic and the most important analysis tool in your improvement armoury.

BMJ Quality & Safety have a very useful article with instructions on how to create a run chart and how to interpret it: click here to go to the article

Quality Improvement Collaboratives - New Paper

2012-02-10T08:05:00.000Z

There's a new paper out (see below) which comes to a conclusion similar to ones found a few years ago - namely, in Quality Improvement Collaboratives, teams where the members have low knowledge of the topic or improvement science, are the ones which come out best. It also demonstrates that good leadership trumps the teaching of theory.

I've always thought that the more we push theory under the guise of "Improvement Science" at these short term interventions, the more we may confuse participants and in fact create a type of "performance anxiety" where they become afraid of doing what comes naturally, because it has been turned into what appears to them as a right-wrong application.

Implement Sci. 2012 Jan 9;7(1):1. [Epub ahead of print]
Factors associated with the impact of quality improvement collaboratives in mental healthcare: an exploratory study.
Versteeg MH, Laurant MG, Franx GC, Jacobs AJ, Wensing MJ.

ABSTRACT:
BACKGROUND:
Quality improvement collaboratives (QICs) bring together groups of healthcare professionals to work in a structured manner to improve the quality of healthcare delivery within particular domains. We explored which characteristics of the composition, participation, functioning and organization of these collaboratives related to changes in the healthcare for patients with anxiety disorders, dual diagnosis, or schizophrenia.

METHODS:
We studied three QICs involving 29 quality improvement (QI) teams representing a number of mental healthcare organizations in the Netherlands. The aims of the three QICs were the implementation of multidisciplinary practice guidelines in the domains of anxiety disorders, dual diagnosis, and schizophrenia, respectively. We used eight performance indicators to assess the impact of the QI teams on self-reported patient outcomes and a number of process of care outcomes for 1.346 patients. The QI team members completed a questionnaire on the characteristics of the composition, participation in a national program, functioning and organizational context for their teams. It was expected that an association would be found between these team characteristics and the quality of care for patients with anxiety disorders, dual diagnosis, and schizophrenia.

RESULTS:
No consistent patterns of association emerged. Theory-based factors did not perform better than practice-based factors. However, QI teams that received support from their management and both active and inspirational team leadership showed better results. Rather surprisingly, a lower average level of education among the team members was associated with better results although less consistently than the management and leadership characteristics. Team views with regard to the QI goals of the team and attitudes towards multidisciplinary practice guidelines did not correlate with team success.

CONCLUSIONS:
No general conclusions about the impact of the characteristics of QI teams on the quality of healthcare can be drawn, but support of the management and active, inspirational team leadership appear to be important. Not only patient outcomes but also the performance indicators of monitoring and screening/assessment showed improvement in many but not all of the QI teams with such characteristics. More studies are needed to identify factors associated with the impact of multidisciplinary practice guidelines in mental healthcare.

Systematic Review of Communities of Practice in Healthcare

2011-11-22T10:54:00.000Z

I love systematic reviews. They are hard work, major undertakings and make life much easier for the rest of us. Compliments to the authors of this new paper which can be accessed online.

How and why are communities of practice established in the healthcare sector?
A systematic review of the literature.

Geetha Ranmuthugala, Jennifer J Plumb, Frances C Cunningham, Andrew
Georgiou, Johanna I Westbrook, Jeffrey Braithwaite

Australian Institute of Health Innovation, University of New South Wales, Sydney,
NSW 2052, Australia.

Does opinion leadership change over time? New Research

2011-11-14T10:35:00.001Z

I'm pleased to see useful research is being done to clarify further what we mean by opinion leadership. Too often I hear people reducing what is a very complex topic to a simple slide of Roger's characteristics. Roger's initial work on the Diffusion of Innovations was researched and published before the age fo the Internet and before many staff were born. We need updates and we need to grasp a deeper understanding of the complexities.

There's a new paper out.
Implement Sci. 2011 Oct 11;6(1):117. [Epub ahead of print]
Opinion leaders and changes over time: a survey.
Doumit G, Wright FC, Graham ID, Smith A, Grimshaw J.

I've posted the conclusions to this paper below - and recommend you read the original.

"CONCLUSIONS:
Opinion leaders identified in this study were not stable over a two-year time period and generally appear to be monomorphic with clearly demarcated areas of expertise and limited spheres of influence. These findings may limit the practicability of routinely using opinion leaders to influence practice."

Meeting Agenda Good Practice

2011-11-09T11:42:00.000Z

I've been on a mission for some years to get agendas for meetings organised and prepared in a way that supports an efficient and effective process. here are many ways to do this and a recent post from Radcliffe Learning [this link is no longer working but I'm leaving this live while I try to find another way to get to the info as it is really useful. It comes from Radcliffe Publishing and you can view earlier editions of their newsletter here)] has some excellent advice. I particularly like the way they suggest the agenda items are to be divided into:

· Part 1: Items requiring a decision today

· Part 2: Items requiring discussion today

· Part 3: Items for information only today

What's your favourite tip for great meetings?

Overcoming resistance to change

2011-11-06T13:33:00.000Z

Resistance to change is on that "Top Five" list of topcis I get aksed about.

I think the video below is a great answer to the question on how to overcome resistance to change:

Where are the negative studies?

2011-11-04T13:27:00.000Z

I've written about his before, but I am still concerned about the lack of will to share what doesn't work in quality improvement initiatives. I worry that improvement leaders are so concerned about telling their sponsors that the work is doing very well, that they can't face the less than successful projects. We all know we learn from mistakes - in fact one of the basic tents of quality improvement is the importance of testing and learning (from the good and the bad).

I keep threatening to start the Journal for Quality and Safety Initiative Learning/Mistakes/Failures/Messes. When I figure the title I'll get it going. Any suggestions?

Predicting implementation success from organisational readiness

2011-11-01T13:21:00.000Z

I've wondered for a while whether there is any evidence that we can predict the success of a change based on the organisation's readiness for the change - else why would we bother with worrying about readiness? As always, loads of researchers have not only been worrying about this issue, they have also been investigating it. I found numerous papers, however, one captured my interest - probably because of the rational and detailed way in which the research was conducted. The conclusion as I figure it, is that it all depends on the biases (or not) in the readiness instrument.

You can read this paper here.

The meaning of Implementation Climate

2011-10-30T13:15:00.000Z

I've just read a new paper about implementation climate and how it differs from organisational climate - all part of the "readiness for change" strategies than many of us use. You can read the whole paper at Implementation Science (online - open access). I've pasted the abstract here, though I recommend you read the whole paper.

The meaning and measurement of implementation climate.

Weiner BJ, Belden CM, Bergmire DM, Johnston M.

Abstract

BACKGROUND:

Climate has a long history in organizational studies, but few theoretical models integrate the complex effects of climate during innovation implementation. In 1996, a theoretical model was proposed that organizations could develop a positive climate for implementationby making use of various policies and practices that promote organizational members' means, motives, and opportunities for innovation use. The model proposes that implementation climate--or the extent to which organizational members perceive that innovation use is expected, supported, and rewarded--is positively associated with implementation effectiveness. The implementation climate construct holds significant promise for advancing scientific knowledge about the organizational determinants of innovation implementation. However, the construct has not received sufficient scholarly attention, despite numerous citations in the scientific literature. In this article, we clarify the meaning of implementationclimate, discuss several measurement issues, and propose guidelines for empirical study.

DISCUSSION:

Implementation climate differs from constructs like organizational climate, culture, or context in two important respects: first, it has a strategic focus (implementation), and second, it is innovation-specific. Measuring implementation climate is challenging because the construct operates at the organizational-level, but requires the collection of multi-dimensional perceptual data from many expected innovation users within an organization. In order to avoid problems with construct validity, assessments of within-group agreement of implementationclimate measures must be carefully considered. Implementation climate implies a high degree of within-group agreement in climate perceptions. However, researchers might find it useful to distinguish implementationclimate level (the average of implementation climate perceptions) from implementationclimate strength (the variability of implementation climate perceptions). It is important to recognize that the implementationclimate construct applies most readily to innovations that require collective, coordinated behavior change by many organizational members both for successful implementationand for realization of anticipated benefits. For innovations that do not possess these attributes, individual level theories of behavior change could be more useful in explaining implementation effectiveness.

SUMMARY:

This construct has considerable value in implementation science, however, further debate and development is necessary to refine and distinguish the construct for empirical use.