Precision Tailoring of Implementation Strategies Predrag Pedja - PowerPoint PPT Presentation

Precision Tailoring of Implementation Strategies Predrag “Pedja” Klasnja Kaiser Permanente Washington Health Research Institute

How do we do better?

Implementation Strategy Optimization Goals Develop blended strategies that only contain component strategies… • That are likely to be effective for prioritized determinants • For which all key preconditions are present • That interact synergistically

Implementation Strategy Optimization Goals Develop blended strategies that only contain component strategies… • That are likely to be effective for prioritized determinants • For which all key preconditions are present • That interact synergistically

Causal Pathway Diagramming

Distal Outcomes Implementation outcomes that the implementation effort, as a whole, is intended to influence. Distal outcome: high level of therapist use of CBT techniques (organizational level outcome) Use of CBT

Target Determinants Factors that prior work has identified as having an influence on desired distal outcomes • Key targets for change by implementation strategies • Each strategy should target at least one prioritized determinant Example determinants: High • Participation in EBP initiatives participation Use of CBT (individual level) in EBP initiatives • Proficient culture (org level)

Candidate Strategy A strategy being considered for inclusion in a blended package that we think—based on theory, prior work, etc.—might be effective at influencing a prioritized determinant Example : incentives for participation in EBP initiatives (org. level) Higher Incentives for participation Use of CBT participation in in EBP EBP initiatives initiatives

Mechanism Process through which the candidate strategy is hypothesized to affect its target determinant • What steps need to take place for the strategy to influence the determinant? • How quickly/slowly would this process work? • Is the mechanism likely to have a strong enough effect on the determinant to make the use of strategy clinically meaningful? Example mechanism: operant conditioning / positive reinforcement (individual level)

Preconditions Factors that are necessary (but possibly not sufficient) conditions for the strategy to work via postulated mechanism • Can function at different levels (cognitive, organizational, etc.) • Can vary from site to site Examples: • EBP initiatives are available for clinicians to attend (org level, broader clinical environment) • Incentives allowed in the organization (org level) • EBP initiative participation can be monitored to enable incentive disbursement (technological level)

Higher Incentives for Positive participation participation in Use of CBT reinforcement in EBP EBP initiatives initiatives EBP initiatives available for attending (…)

Proximal Outcomes Observable, measurable, short-term changes that indicate that the strategy is having an impact • Should be in the causal path to the target determinant • Should provide evidence on the hypothesized mechanism Example proximal outcome: registration for the next EBP initiative within 30 days of incentive payout (individual level)

Higher Incentives for EBP Positive participation participation in Use of CBT initiative reinforcement in EBP EBP initiatives registration initiatives EBP initiatives available for attending (…)

Effect moderators Factors that can strengthen or diminish the effect of the strategy on its downstream outcomes. Moderators… • May vary across individuals and/or sites • Can help explain heterogeneity in outcomes • Can guide strategy design Example moderators: • Perceived value of the incentive (cognitive [individual] level) • Immediacy of incentive payout (technological/organizational level) • Reinforcement schedule (strategy design)

Incentive Immediacy Higher Incentives for EBP Positive participation participation in Use of CBT initiative reinforcement in EBP EBP initiatives registration initiatives EBP initiatives Perceived available for value attending (…)

Other Considerations • A single strategy may influence multiple determinants • A single strategy may work through multiple mechanisms • A single determinant may get influenced by multiple strategies (look for synergies) • incentives for EBP initiative participation may signal that proficiency is valued (proficiency culture) • Things can break in several places along the causal path. Proximal outcomes can help figure out where the process went wrong

Summary Causal pathway diagrams can… • Help articulate how an implementation strategy is thought to influence its target determinants • Act as checks on feasibility and likely magnitude of this influence • Ensure that all necessary conditions for a strategy’s functioning are present in the current clinical setting • Point to important factors that should be addressed in strategy design • Indicate constructs that should be measured to explain how well the strategy worked (or didn’t work)