Using Im Implementation Strategy Designs to Promote Adaptation Amy M. Kilbourne, PhD, MPH Quality Enhancement Research Initiative (QUERI), US Dept. of Veterans Affairs Department of Psychiatry, University of Michigan Medical School amykilbo@umich.edu 9th Annual Conference on the Science of Dissemination and Implementation, 2016
Current Adaptation Initiatives in VA • “Rea l- time” adaptation of evidence -based practices: Triple Aim QUERI • Modified Stirman Adaptations and Modifications Framework/RE-AIM • QUERI-wide Special Interest Group on Fidelity, Adaptation, and Tailoring • Adaptation of the implementation process: Virtual Specialty Care QUERI • SMART stepped-wedge designs • Implementation strategies for PTSD telehealth • Promoting Positive Deviance: VHA Diffusion of Excellence Initiative (DEI) • Launched by VHA in 2015 to promote bottom-up ID, spread of best practices • QUERI investigators collaborating with VHA leadership on DEI national evaluation Refs: Chambers and Norton, The Adaptome: Advancing the Science of Intervention Adaptation; AJPM 2016 Shulkin D, Beyond the VA Crisis--Becoming a High-Performance Network, NEJM 2016 Atkins, Kilbourne, Shulkin, Role of Research in a Learning Health Care System, ARPH, in press, 2017
Allowing adaptation of EBPs enables ownership of the QI process e.g., Dynamic Adaptation Process Model, Replicating Effective Programs (REP) Pre-implementation Implementation Sustainability Training Monitor fidelity Multilevel assessment Technical assistance ID adaptations- Response Provider/System Strategies stakeholder input Retention Coaching Prepare adaptations Facilitation Business case e.g., Core elements Strategic thinking Menu options Ongoing feedback Refs: Aarons et al. (2012) Dynamic Adaptation Process Model Wiltsey-Stirman et al. (2013) framework Kilbourne (2007, 2012) Enhanced Replicating Effective Programs Framework
SMART Designs: Tailor Implementation Strategies Follow Up ADEPT Study Start Phase 2 Month 18 and 24 Month 6 Month 12 Run-In Phase Assessments Assessment Assessment All sites offered REP to implement EBP; Continue follow- Continue follow-up Patients start EBP by Responders up assessments assessments (A) REP+EF Month 3 Continue Continue Add External REP+EF REP+EF (B) Non- Facilitation R Non- responders Add IF Continue Responders REP REP+EF/IF REP+EF/IF (C) (<10 out of 20 R sites Responders enrolled REP+EF/IF Continue follow- Continue follow-up patients up assessments assessments (D) Add Internal & receiving EBP External or <75% Non- Continue Continue Facilitation sessions responders REP+EF/IF REP+EF/IF (E) completed) 6 Month follow- Continue follow- Continue follow-up Responders up assessment up assessments assessments (F) Kilbourne, Almirall, et al Adaptive Implementation of Effective Programs Trial (ADEPT), Imp Sci 2014
SMART Designs Inform Adaptive Implementation Interventions An example using Standard REP & Facilitation in community practices: Adapted from NIMH ADEPT Trial: R01 MH099898 (PI: Kilbourne)
Enabling Adaptation of the Implementation Process: Examples of QUERI Implementation Strategies 1.2 Learning LEAP Collaboratives (Learn, Engage, Act, 1 Process) Community EBQI Engagement 0.8 (Evidence-based Quality Improvement) 0.6 Replicating Tim ime/ Systems Redesign Effective Programs In Intensit ity 0.4 Facilitation Audit & Feedback of Im of Imp. Un-learning: Str trategy Barrier Buster 0.2 Academic Detailing 0 Sit ite e Factors (Ne (Need, Ba Barrie iers)
Promoting Positive Deviance: VA’s Diffusion of Excellence Initiative Infrastructure Social media platform promotes conversation and sharing about promising practices Virtual VA “Shark Tank” style event enabled virtual engagement in unique opportunity to ‘pitch’ promising practices Diffusion Hub provides robust project management and tracking tools to manage replication and implementation of best practices, all based on LEAN principles and frameworks Acknowledgements: Shereef Elnahal, MD, Deputy Undersecretary for Quality & Safety, VA Office of Organizational Excellence Diffusion of Excellence-QUERI Evaluation leads: George Jackson, Laura Damschroder, Tom Houston
“Let the other person feel that the idea was his or hers” - Dale Carnegie THANK YOU! VA Quality Enhancement Research Initiative (QUERI) http://www.queri.research.va.gov/ 10
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