Using Implementation Science to Effectively Implement Evidence-Based Practices

Heather J. Gotham, PhDMid-America ATTC

UMKC School of NursingHealth Literacy: A prescription for Patient Engagement

February 12, 2013

“As clinicians, what we say does not matterunless patients are able to understandthe information we give them well enough to use it to make good health-care decisions. Otherwise we didn’t reach them,and that is the same as ifwe didn’t treat them.”

United States Surgeon General; Benjamin, 2010

Objectives

1. Define implementation and implementation science

2. Describe the implementation gap and its effects on evidence-based practices

3. Describe 4 strategies from implementation science research to assist with organizational changes and promote the best patient outcomes

Implementation

• Incorporating an innovation into routine practice.

• Includes a range of strategies to address individual, organizational, and systemic characteristics (e.g., skills training, administrative buy-in, policy changes).

ATTC Technology Transfer Workgroup, 2010

Implementation Science

• Combines research across fields– Rural sociology– Medical sociology – Communication & marketing– Evidence-based medicine– Organizational change

• Studies how evidence-based practices are used in the real world

• Studies what strategies can help most efficiently implement evidence-based practices

Greenhalgh et al., 2004

Grei

“Passive approaches are generally ineffective and unlikely to result in behavior change.” (Grimshaw 2001)

“Train and hope” doesn’t work either. (Stilen 2013)

Effective Intervention X

Ineffective or Insufficient

Implementation=

Inconsistent;Not Sustainable;Poor Outcomes

The Implementation Gap

http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

Assertive Community Treatment– Patients with mental health and substance use disorders– Treatment using multi-disciplinary team

Strong Implementation (High Fidelity)

ACT team

Weak Implementation (Low Fidelity)

ACT team

Treatment Drop-outs 15% 30%

Substance Use in Remission 55% 13%

Hospital Admissions 2.87 4.69

McHugo et al., 1999

Patient medication adherence

Health professionaladherence to

EBPs

Betterpatienthealth

The Implementation Gap in Healthcare

What Works

Effective NOT Effective

Effective

NOT Effective

IMPLEMENTATION

INT

ER

VE

NT

ION Performance Implementation(High Fidelity)

Paper ImplementationProcedure Implementation (Low Fidelity)

Copyright © Dean L. Fixsen and Karen A. Blase, 2008

Difficult to Change Practice and Make it Stick (Routine)

Use Implementation Science to Create Successful Change

http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

Create a Successful Implementation Team• Organizational Sponsor

– Leads implementation effort, appoints the Change Agent

– Acts as a mentor to maintain enthusiasm– Problem-solver, assists Change Agent and Team

• Change Agent– Overall responsibility for implementation and plan– Supervisory position with responsibility and authority

to implement policy and programmatic changes– Recognized/respected for leadership, organizational

savvy, and persistence

Create a Successful Implementation Team

• Implementation Team– Comprised of staff from all levels/roles

• Administrative, Supervisory, Support, Technical and/or IT• Patients

– Meet regularly– Review implementation planning

Create a Successful Implementation Team

Implementation Drivers

http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

Key elements of capacity and infrastructure that influence a program’s success

 

 OUTCOMES(% of Participants)

TRAININGCOMPONENTS

KnowledgeSkill

DemonstrationUse in the Classroom

Theory and Discussion

 

10% 

5% 0%

..+Demonstration in Training

30%20%

0%

..+ Practice & Feedback in Training

60% 60% 5%

..+ Coaching in Classroom

95% 95% 95%  

Joyce and Showers (2002) study of implementing new education practices in the classroom

Implementation Drivers: Training alone is never enough

Implementation Drivers

INTEGRATED & COMPENSATORY

CONSULTATION & COACHING

CONSULTATION & COACHING

STAFF PERFORMANCE EVALUATION

STAFF PERFORMANCE EVALUATION

FACILITATIVE ADMINISTRATIVE

SUPPORTS

FACILITATIVE ADMINISTRATIVE

SUPPORTS

RECRUITMENT AND SELECTION

RECRUITMENT AND SELECTION

PRESERVICE TRAINING

PRESERVICE TRAINING

SYSTEMSINTERVENTIONS

SYSTEMSINTERVENTIONS

DECISION SUPPORT DATA SYSTEMS

DECISION SUPPORT DATA SYSTEMS

Must be addressed for successful implementation

Implementation Research, Fixsen et al., 2005; http://nirn.fpg.unc.edu/

Use Implementation Drivers to Develop an Implementation Plan

Implementation Driver

 Implementation StepsStaff

Person(s) 

Deadline Comments

Recruitment/ Staff Selection

Implementation Team1. Finalize Implementation Team Change

Agent11/11 Completed

2. Meet every 2 weeks through March, then re-evaluate

Team 11/18

Facil. Admin. Supports

Screening Process1. What is currently done? Are nurses already doing EMR Screening?

Change agent, head nurse

11/18  

Decision Support Data Systems

EMR1. Determine issues and system limits with EMR What if only some items are completed? Can all staff complete the screener?

Admin staff with IT staff

11/15 initial report

Review at 11/18

meeting 

Training

Targeted training needed for all levels of staff1. Education for nurses on all shifts Health coach

supervisor11/18

Improvement Cycles

http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

Improvement cycles and other quality improvement strategies help you to manage the changes being implemented and to keep the focus on what is working.

Improvement Cycles

Plan: Plan the change using the implementation plan

Do: Make the change

Study: Evaluate what happened

Act: Continue or go back to planning

Implementation Stages

http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

Every change in clinical practice goes through multiple stages from exploring the options for change through fully implementing the change. The whole process takes several months to years.

Implementation Stages

Initial Implementation•Implementation drivers•Manage change & expectations•Improvement cycles•Learn from mistakes•Celebrate progress

FullImplementation•Implementation drivers•Monitor outcomes•Improvement cycles•Components integrated•Fully functioning•Sustainability

Installation•Acquire resources•Create implementation plan•Develop infrastructure•Prepare staff

Exploration•Assess needs•Examine innovations•Assess fit•Promote “buy in”

From: http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

Use Implementation Science to Create Successful Change• Teams

– Build an implementation team

• Drivers– Training alone is never enough– Detailed implementation plan

• Improvement Cycles– PDSA cycles

• Stages– Implementing new practices takes months to years– Recognize the change process

http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

Practices are Abandoned….

Five warning signs for De-adoption of EBPs

Massatti et al., 2008

Lack of ongoing resources

Massatti et al., 2008

Lack of support from external groups of the effort to change

Massatti et al., 2008

Attitudes about the new practice – think we do it already versus open to learning and changing

Massatti et al., 2008

Beliefs that the new practice does not fit with our knowledge/skills or the agency’s mission/philosophy

Massatti et al., 2008

Beliefs that the new practice is neither easy to implement nor a permanent part of the agency’s services

Massatti et al., 2008

Sustainability

• Plan for sustainability as you’re writing the grant/planning the project

• Prepare for turnover– Develop expertise in the agency– What are your re-training plans?

• Plan for continued resources where needed• Outcome data/continuous quality improvement

Contact

Heather J. Gotham, PhD

Associate Research Professor

Mid-America ATTC

UMKC School of Nursing

gothamhj@umkc.edu

direct (816) 235.5058