A skills building series January 25 2018 Engage with CIIS Overview Implementation amp Improvement Sciences Implementation Science Focuses on optimal strategies to promote evidence uptake in realworld ID: 712220
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Slide1
Transforming Implementation & Improvement Into Science: A skills building series
January 25, 2018Slide2
Engage with CIISSlide3
Overview: Implementation & Improvement Sciences
Implementation Science
Focuses on optimal strategies to promote evidence uptake
in real-world
settings
Improvement Science
Focuses on rigorously measuring outcomes associated with efforts to improve care delivery
AddressesDid the new endeavor measurably improve desired outcomes?
AddressesDid stakeholders perform the desired endeavor? Why or why not?How well?
Aims
Translate research intro practice
Systematically implement evidence-based practices
Improve the quality of healthcare Slide4
Overall impactSignificance
Innovation
Approach
Investigator team
Research environment
Identifying High-Quality ProjectsB
road, non-specific to IISCriteria could be operationalized to better describe high-quality IISMain NIH Criteria
Issues Applying NIH Criteria to Implementation & Improvement (IIS)Slide5
Proctor’s 10 Key Ingredients for Implementation Research Proposals
Proctor’s 10 Key Ingredients
NIH Criteria
Quality/care gap
Impact; Significance
Evidence-based treatment
Significance;
Innovation
Conceptual model, theoretical justificationApproach; Innovation
Stakeholder priorities, engagement in change
Impact; Approach; Research Environment
Setting’s readiness to adopt new services
Impact; Approach; Environment
Implementation strategy/process
Impact; Significance; Innovation
Team experience with the setting, treatment, processes
Approach; Investigator Team
Feasibility of proposed research design
Approach; Investigator
Team
Measurement & analysis section
Approach; Investigator TeamPolicy/funding environment; support for sustaining changeImpact; Significance
Source:
Writing Implementation Research Grant Proposals: Ten Key Ingredients. Proctor EK, Powell BJ, Baumann AA, Hamilton AM,
Santerns
RL.
Implementation Science.
2012;7:96.Slide6
Tentative Date
Session Title
Proposal
Areas Addressed
10/25/2017
Identifying Your Implementation & Improvement Sciences Research Question
Quality/Care Gap, Evidence-Based Practice
12/6/2017
Using & Discussing Implementation Science Models
Conceptual Model1/25/2018
Implementation Strategies Versus Study Interventions
Implementation Strategy2/28/2018
Designing an Implementation & Improvement Sciences StudyStudy
Design
3/22/2018
Designing Your Implementation & Improvement Sciences Study
Study Design
[PRACTICE-BASED
SESSION]
4/18/2018
Measuring
Implementation & Improvement
OutcomesOutcomes, Quantitative & Qualitative Methods5/10/2018Engaging with Stakeholders to Conduct Feasible & Meaningful ResearchStakeholder Engagement, Feasibility, Team, Policy Environment
Upcoming SessionsSlide7
Series Goal
Proctor’s 10 Key
Ingredients
CIIS Educational Series
High-Quality
Implementation & Improvement Sciences
Significant Contributions to Improve Care, Advance FieldsSlide8
Differentiate between implementation strategies & intervention componentsDiscuss how to link implementation strategies to study aims, setting, process & outcome measures
Provide examples of how to navigate challenges associated with chosen implementation strategies
Implementation Strategies vs. InterventionsSlide9
Megan McCullough, PhD
Implementation Strategies vs. Study Interventions
Research Health Scientist
Center for Healthcare Organization & Implementation Research (CHOIR)
ENRM Veterans HospitalSlide10
The views expressed in this presentation are those of the authors and do not necessarily reflect the position or policy of the
Department
of Veterans Affairs or the U.S. government.
VA DisclaimerSlide11
Interventions with proven efficacy and effectiveness at improving health behaviors, health outcomes, or health-related environmentsIntervention could include programs, practices, policies
&
guidelines
What is an Evidence-Based Intervention?
Rabin, B. A.,
Brownson
, R. C., Haire-Joshu, D., Kreuter, M. W., & Weaver, N. L. (2008). A glossary for dissemination and implementation research in health.
Journal of Public Health Management and Practice, 14(2), 117-123.; Brown CH, Curran G,
Palinkas LA, Aarons GA< Wells KB, Jones L., et al. An overview of research and evaluation designs for dissemination and implementation. Annu Rev Public Health,. 2017; 38:1-22Slide12
Implementation research: scientific
study of the use of
strategies
to adopt & integrate evidence-based health interventions into clinical and community settings in order to improve patient/population
outcomes
Implementation Research/Strategies
Proctor EK, Powell BJ, McMillen JC. Implementation Strategies: Recommendations for Specifying and Reporting.
Implementation Science. 2013;1(8):139.; Proctor EK, Landsverk J, Aarons G, Chambers D, Glisson C, Mittman
B. Implementation Research in Mental Health Services: An Emerging Science with Conceptual, Methodological, and Training challenges. Administration and Policy in Mental Health and Mental Health Services Research. 2009;36(1):24-34. doi:10.1007/s10488-008-0197-4.“Methods or techniques used to enhance adoption, implementation, & sustainability of a clinical program or practice” (Proctor et al., 2013)
(Proctor et al., 2009)Slide13
Recommendations for Specifying & Reporting
Name the strategy
Define the strategy
Specify the strategy
The actor (who enacts the strategy)
The action (use active verb statement to specify the specific actions, steps, or processes that need to be enacted)
Action target
(specify
targets and identify units of analysis)
Temporality (when the strategy is used)
Dosage
Implementation outcome affected
Justification
Proctor EK, Powell BJ,
McMillen
JC. Implementation Strategies: Recommendations for Specifying and Reporting. Implementation
Sicence
. 2013;1(8):139.Slide14
Thoughts?Discussion?
Questions?Slide15
Hybrid Study Type 2
Operationalizing an Example:
The Anticoagulation Clinic Improvement Initiative (ACCII)Slide16
Use evidence-based dosing algorithmAlgorithm linked to improve percent time in therapeutic range (TTR)Higher TTR = improved patient outcomes
Use a dashboard to measure site-level TTR & related process measures
Utilize improvement approaches to increase standardization across facilities
Appoint an ACC Coordinators (internal facilitators) from each site to facilitate change
ACCII Study: OverviewSlide17
Promoting Action on Research Implementation in Health Services (PARIHS) Framework
Facilitation:
Concerned with enabling
&
supporting the implementation of an intervention through deployment of EF
& IF
Evidence:
Stakeholder’s perception of validity of intervention & EBP algorithm
Context:
Environment where ACCII is
introduced:
m
ay
be more or less receptive to change
ImplementationSlide18
Develop a formal implementation blueprint
Assess for readiness
Blended facilitation (focus today)
Stakeholder engagement
Plan Do Study Act
(PDSA) cycles
Educational outreach visitsACCII Study: Bundle of Implementation Strategies Local needs assessment
Ongoing training Create a learning collaborative Inform local opinion leadersOngoing consultation
Tailor strategiesVisit other sitesHow we got the intervention implemented (Powell et al., 2015)
Powell BJ, Walz
TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK, Kircher
JE. A Refined Compilation of Implementation Strategies: Results from the Expert Recommendations for Implementing Change (ERIC) Project. Implementation Science. 2015;10:21.Slide19
ACCII Study
: MethodsSlide20
Year
# Main Study Interviews
# Internal
Facilitator
Interviews
# External
Facilitator
Interviews
16711
2
6312
3
6712
5
4
57
12
Total
254
47
5
ACCII Study
: ParticipantsSlide21
Exploration of intervention & strategy togetherACCII example: blended facilitation
ACCII
Study: Intervention & StrategySlide22
Organize face-to-face meeting quarterly for ACC coordinators Introduced ACC coordinators to:
LEAN
Process mapping
PDSAs & other quality improvement skills
I
mplementation strategies Work 1:1 with ACC coordinatorsAudit & feedback for ACC coordinatorsACCII Study: External Facilitation Strategies
Facilitate bi-monthly calls for ACC coordinatorsFacilitate ACC journal clubAnnual site visits with focused improvement workEnlist stakeholders to support ACCIIDraft policy documents & shepherd policy proposals through committees for approvalSlide23
Organize face-to-face meeting quarterly to learn:Quality improvement approachesProcess mapping & evaluation
Group activities to standardize & centralize
Twice
monthly ACC Coordinator’s calls
ACCII Study
: Internal Facilitation Strategies
Work 1:1 with external facilitation staffSite visit to Portland, OR to visit top performing VA ACCFacilitating implementation of ACCII at home siteServing as resource/support for frontline staff during ACCIISlide24
What are the challenges? How have you measured these in your projects?
ACCII Study
: Implementation OutcomesSlide25
ACCII Study: Uptake of Intervention
Uptake of Intervention
Clinical Intervention
Uptake
Levels
High
Medium
Low
ACC Dosing Algorithm
Algorithm is implemented & used a
high percentage of the time by all staff
Algorithm is inconsistently used among staff
Algorithm is rarely used among all staff
Dashboard
Dashboard is used not only to measure performance, but as a tool for targeting patients needing
more attention
Most or all staff increasing use of dashboard
Dashboard is used to measure performance & only 1-2
features used inconsistently as a tool
Often only select staff use the dashboard with little or no general usage
Dashboard
used rarely to measure performance & rarely or not at all as a tool
Little to no general usage & little or no select staff usageTime in Therapeutic Range (TTR)TTR improvesTTR shows some improvement
TTR shows little improvement
McCullough MB, Gillespie C, Petrakis BA, Jones, EA, Park AM, Lukas CVD, Rose AJ. Forming and Activating an Internal Facilitation Group for Successful Implementation: A Qualitative Study.
Research in Social and Administrative Pharmacy.
2017:1-14.Slide26
ACCII Study: Uptake of Intervention
Implementation
Outcomes
Participation in Activities:
Uptake
Levels
High
Medium
Low
ACC Coordinators
IF Group
Site regularly sends appropriate IF to participate
Site
inconsistently sends IF to participate
Site rarely or never sends IF to participate
Journal Club (IF,
staff
)
Staff regularly participate & contribute
Staff unevenly
participate & contribute
Staff rarely or never participate &
contributePDSA cycles related to ACC improvement led by IFIF has staff regularly participateIF has staff inconsistently participate
IF has staff rarely participate
IF facilitates feedback from frontline staff to EF on implementation work
IF regularly elicits feedback
IF inconsistently elicit
s feedback
IF rarely participate
Site seeks out &/or accepts assistance by EF ACC Improvement Team
IF & site reach out for assistance & remain in contact with EFs
IF & site unevenly reach out for
assistance from EFs
IF & site do not reach out for assistance, does not respond to EFs offers of assistance
McCullough MB, Gillespie C, Petrakis BA, Jones, EA, Park AM, Lukas CVD, Rose AJ. Forming and Activating an Internal Facilitation Group for Successful Implementation: A Qualitative Study.
Research in Social and Administrative Pharmacy.
2017:1-14.Slide27
Thoughts?Discussion on importance of outcome measures
ACCII Study
: Outcome MeasuresSlide28
ACCII Study: Outcome Measures
Rose AJ, Park A, Gillespie C, Lukas CVD,
Ozonoff
A et al. Results of a Regional Effort to Improve Warfarin Management. Annals of Pharmacology. 2017.Slide29
ACCII Study: Outcome Measures
Rose AJ, Park A, Gillespie C, Lukas CVD,
Ozonoff
A et al. Results of a Regional Effort to Improve Warfarin Management. Annals of Pharmacology. 2017.Slide30
ACCII Study: Outcome Measures
Abbreviations:
TTR: Time in Therapeutic Range
VISN: Veterans Integrated Service Network
Rose AJ, Park A, Gillespie C, Lukas CVD,
Ozonoff
A et al. Results of a Regional Effort to Improve Warfarin Management. Annals of Pharmacology. 2017.Slide31
Sites with greater improvement were distinguished by 3 factors:
ACCII Study
: Overall Results for Blended FacilitationSlide32
Blended facilitation can serve as an effective implementation strategy
Findings can help guide researchers who seek to incorporate internal facilitator groups as part of their implementation
strategies
Contributes to a growing literature regarding which implementation strategies work best and under what
circumstances
ACCII Study
: ImplicationsSlide33
Key TakeawaysSlide34
What is your evidence-based intervention?
Framework
&
study design?
What strategies would you use to get the intervention into practice?
How do you determine an intervention versus a strategy?
Tell Me About Your ProjectsWhat are the measures?Outcome measures?Implementation measures?Where do you get stuck? What is a puzzle here that is hard to sort out and solve?Slide35Slide36Slide37
Tentative Date
Session Title
Proposal
Areas Addressed
10/25/2017
Identifying Your Implementation & Improvement Sciences Research Question
Quality/Care Gap, Evidence-Based Practice
12/6/2017
Using & Discussing Implementation Science Models
Conceptual Model1/25/2018
Implementation Strategies Versus Study Interventions
Implementation Strategy
2/28/2018Designing an Implementation & Improvement Sciences Study
Study Design
3/22/2018
Designing Your Implementation & Improvement Sciences Study
Study Design
[PRACTICE-BASED
SESSION]
4/18/2018
Measuring
Implementation & Improvement
OutcomesOutcomes, Quantitative & Qualitative Methods5/10/2018Engaging with Stakeholders to Conduct Feasible & Meaningful ResearchStakeholder Engagement, Feasibility, Team, Policy Environment
Upcoming SessionsSlide38
Contact
CIIS
Website
:
http://sites.bu.edu/ciis/
Email: ciisinfo@bu.eduThank You!