IMPROVEMENT ? How do improvement science and implementation science - PowerPoint PPT Presentation

IMPROVING IMPLEMENTATION OR IMPLEMENTING IMPROVEMENT ? How do improvement science and implementation science contribute to quality and effectiveness in health care? Abe Wandersman, PhD Professor Dept. of Psychology University of South Carolina Rohit Ramaswamy, PhD, MPH Associate Professor Public Health Leadership/Maternal and Child Health University of North Carolina, Chapel Hill

OVERVIEW • Big picture issue • Evidence Based Interventions are necessary but not sufficient for outcomes • Bridging research and practice • The Interactive Systems Framework (ISF) • Readiness • Evidence Based System for Innovation Support (EBSIS) • Integrating Improvement and Implementation: Ghana case study

IMPLEMENTATION AND IMPROVEMENT SCIENCES – CONNECTED BY A COMMON GOAL CONTINUALLY IMPROVE IMPLEMENTATION QUALITY IMPROVEMENT IMPLEMENTATION SCIENCE SCIENCE IMPLEMENT WHAT YOU IMPROVE WITH QUALITY GOOD AND SUSTAINED OUTCOMES

IMPROVING IMPLEMENTATION QUALITY • CQI embedded into common implementation frameworks Quality Implementation Framework Getting to Outcomes NIRN Active Implementation

IMPLEMENTING WHAT IS IMPROVED 1. No tools to guide the actual process of implementation. 2. No formal approach that facilitates adoption of improvement solutions 3. No formal method and tools to adapt improvement solutions to other situations and contexts.

E vidence Based Interventions are Necessary But Not Sufficient for Outcomes

Replication worked (at first)

But Not at Scale

PRACTICE RESEARCH

BR BRIDGING R RESE SEARCH AN AND PR PRACTI TICE * WHERE DO EVIDENCE BASED PRACTICES COME FROM AND WHERE DO THEY GO *RESEARCH TO PRACTICE MODELS *THE INTERACTIVE SYSTEMS FRAMEWORK FOR DISSEMINATION AND IMPLEMENTATION (ISF)

Feedback Loop 2.With an emphasis 1. Identity 3. Design, 4. Design, 5. Facilitate on risk and problem or conduct, and conduct, and large-scale protective factors, disorder(s) and analyze pilot analyze large- implementation review relevant review studies and scale trails of and ongoing information—both information to confirmatory and the preventive evaluation of from fields outside determine its replication trials intervention the preventive prevention and extent of the preventive program intervention from existing intervention program in the preventive program community intervention research programs RISK AND PROTECTIVE EFFECTIVENESS EFFICACY TRIALS PRACTICE FACTORS EPIDEMIOLOGY TRIALS FIGURE 1.1 The preventive intervention research cycle. Preventive intervention research is represented in boxes three and four. Note that although information from many different fields in health research, represented in the first and second boxes, is necessary to the cycle depicted here, it is the review of this information, rather than the original studies, that is considered to be part of the preventive intervention research cycle. Likewise, for the fifth box, it is the facilitation by the investigator of the shift from research project to community service program with ongoing evaluation, rather than the service program itself, that is part of the preventive intervention research cycle. Although only one feedback loop is represented here, the exchange of knowledge among researchers and between researchers and community practitioners occurs throughout the cycle.

Funding Putting It Into Practice— Delivery System Innovation-Specific General Capacity Capacity Use Use Supporting the Work—Support System Macro Climate Policy General Capacity Innovation-Specific Building Capacity Building Distilling the Information— Synthesis & Translation System Synthesis Translation Existing Research and Theory

Interactive Systems Framework for Dissemination and Implementation Delivery System General Capacity

General Capacities Types of General Capacities Authors (non-exhaustive) Culture Drzensky et al., 2012; Glisson, 2007; Glisson & Schoenwald, 2005; Hemmelgarn et al., 2006 Climate Aarons et al., 2011; Beidas et al., 2013; Damschroder et al., 2009; Glisson, 2007; Greenhalgh et al., 2004, Hall & Hord, 2010; Lehman et al., 2002 Organizational Damschroder et al., 2009; Fetterman & Wandersman, 2005; Greenhalgh et al., 2004; Klein & Knight, 2005; Rafferty et al., Innovativeness 2013; Rogers, 2003 Resource Utilization Armstrong et al., 2006; Greenhalgh et al., 2004; Klein et al., 2001; Rogers, 2003; Simpson, 2002 Leadership Aarons & Sommerfield, 2012; Becan, Knight, & Flynn, 2012; Beidas et al., 2013; Fixsen et al., 2005; Grant, 2013; Rafferty et al., 2013; Simpson et al., 2002 Structure Damschroder et al., 2009; Flaspohler et al., 2008; Greenhalgh et al., 2004, Lehman et al., 2002; Rafferty et al., 2013; Rogers, 2003 Staff Capacity Flaspohler et al., 2008; McShane & Van Glinow, 2009; Simpson et al., 2002

GC Components are “Normal” Leadership Low Medium High

Interactive Systems Framework for Dissemination and Implementation Delivery System General Innovation- Capacity Specific Capacity

An Innovation • Any policy, program, or process that is new to a setting

Innovation-Specific Capacities Types of Innovation-Specific Capacities; Authors (non-exhaustive) Innovation-Specific Wandersman, Chien, & Katz, 2012; Fixsen et al., 2005; Greenhalgh et al., 2004; Simpson, 2002 knowledge, skills, and abilities Program Champion Atkins et al., 2008; Damshroder et al., 2009; Greenhalgh et al., 2004; Gladwell, 2002; Grant, 2013; Rafferty et al., 2013; Rogers, 2003 Specific Implementation Aarons et al., 2011; Beidas et al., 2013; Damshroder et al., 2009; Fetterman & Wandersman, 2005; Greenhalgh et al., Supports 2004; Hall & Hord, 2010; Rogers, 2003; Schoenwald & Hoagwood, 2001; Weiner et al., 2008. Interorganizational Aarons et al., 2011; Flaspohler et al., 2004; Powell et al., 2012 Relationships

Interactive Systems Framework for Dissemination and Implementation Delivery System General Innovation- Capacity Specific Capacity Motivation

Motivation for Innovation Types of Motivations Authors (non-exhaustive) Relative Advantage Armenakis et al., 1993; Damschroder et al., 2009; Hall & Hord, 2010; Rafferty et al., 2013; Rogers, 2003; Weiner, 2009 Compatibility Chinman et al., 2004; Durlak & Dupre, 2008; Fetterman & Wandersman, 2005; Greenhalgh et al., 2004; Rogers, 2003; Simpson, 2002 Complexity Damschroder & Hagedorn, 2011; Fixsen et al., 2005; Greenhalgh et al., 2004; Meyers, Durlak & Wandersman, 2012; Wandersman et al., 2008. Trialability Armenakis et al., 1993; Greenhalgh et al., 2004; Rapkin et al., 2012; Rogers, 2003 Observability Beutler, 2001; Chinman et al., 2004; Damschroder et al., 2009; Ford et al., 2008; Rossi, Lipsey, & Freeman, 2004 Priority Armenakis & Harris, 2009; Greenhalgh et al., 2004; Flaspohler et al., 2008

A Heuristic R eadiness i = M otivation i x General C apacity x Innovation-Specific C apacity i R = MC 2

Interactive Systems Framework for Dissemination and Implementation Delivery System General Innovation- Capacity Specific Capacity Motivation Readiness Building Strategies Support System General Innovation- Motivation Capacity Specific Capacity

Buildi ding R ng Readi diness ness Broad Strategies

Ways to support an Innovation Training Tools Technical Quality Assistance Assurance/ Quality Improvement Evidence-Based System for Innovation Support (EBSIS) (Wandersman, Chien, & Katz, 2012)

Testing out systems to help assess and develop readiness and capability: Building Readiness Through an Evidence-Based System for Implementation Support (EBSIS) Relationships Readiness Training Outcomes Improved: Initial Readiness • General • General To Capacities Capacity Achieve Technical Tools Desired • Innovation- Assistance • Innovation Outcomes Specific - Specific Capacities Capacity • Motivation • Motivation Quality Assurance Quality Improvement

IMPLEM EMEN ENTATION

Definition of Quality Implementation We define quality implementation as putting an innovation into practice in a way that meets the necessary standards to achieve the innovation's desired outcomes

SYNTHESIS OF IMPLEMENTATION FRAMEWORKS Meyers, Durlak & Wandersman 2012 • Review of implementation frameworks • Implementation Action strategies used in Iiterature · Action steps for implementing technologies, practices, and/or processes in organizations and/or communities • 25 frameworks were retained (e.g., framework by Dean Fixsen and colleagues)

Synthesis Methodology · Quantitative and qualitative articles were retained • Peer-reviewed publications, book chapters, dissertations, or non-peer-reviewed monographs • Articles which were retained had to include an implementation framework

What is Practical Implementation Science? A user-friendly translationof the results of implementation science