Implementation of Research
Call for Papers Session
Implementation of Research
Chair: Jacqueline Pugh, M.D.
Tuesday, June 5 • 10:45 a.m.-12:15 p.m.
ƒ Development and Testing of an Adoption Decision
Guide for Patient-Centered and Efficiency Innovations in
Health Care
Nancy Lenfestey, M.H.A., Amy Roussel, Ph.D., Jacqueline
Amoozegar, B.A., Asta Sorensen, M.A., Cindy Brach, M.P.P.
Presented By: Nancy Lenfestey, M.H.A., RTI International,
3040 Cornwallis Rd, RTP, NC 27709, Phone: (919) 271-3834,
Fax: (919) 541-7384, Email: nlenfestey@rti.org
Research Objective: The purpose of this project is to develop
and test a decision guide for adoption of innovations in health
care. Innovations in care delivery are often complex, multifaceted interventions that are not fully explicated, and thus
present challenges for organizations in determining whether
an intervention’s components are adaptable in different
organizational cultures. Guided by a framework that
understands adoption as a process, rather than an event, we
developed a multilayered adoption decision guide promoting
evidence-based decision making to assist organizational
decision makers in determining whether an innovation would
be a good fit ---- or an appropriate stretch -- for their
organization.
Study Design: Selection of preliminary domains for the
adoption decision guide was based on: 1) information
obtained from a series of semi-structured telephone interviews
with leaders from up to six health care organizations that
implemented efficiency-focused innovations, four with patientcentered care innovations, and five with innovations focused
on both; and 2) an internet search and literature scan for
relevant decision making tools, guidelines and other resources
to assist leaders in their decision making processes. The
interviews will be supplemented by case studies of 4-6
adopting organizations. QSR NVivo 7, a qualitative software
analysis package, was used for inductive/deductive coding and
analysis. Usability testing of the draft instrument is expected
to occur in several diverse health care settings in May 2007,
with a finalized adoption decision guide available in June
2007.
Population Studied: This study focuses on the adopting
organization as the unit of analysis, rather than the individual
adopter. The purposive sample of health care organizations
was stratified by type of facility, population serviced, and
characteristics of the adopted innovation including
technological complexity, orientation towards people vs.
technology, and degree of implementation complexity. We
attempted to include a diversity of priority service populations
and range of settings including health plans, hospitals,
physician practices, and non-profit organizations.
Principle Findings: The decision guide includes the following
dimensions: innovation description; goal identification and
potential benefits; staff/patient/client readiness for change;
appropriateness; decision-making; observability; replicability;
level of resources needed; compatability/practicality; potential
barriers/challenges; trialability; and sustainability. Assessing
staff readiness for change, the innovation’s alignment with the
organization’s mission, anticipated cultural changes, and the
potential organizational impact of an innovation resonate as
strong considerations in the adoption decision process. The
decision guide highlights each dimension’s importance and
offers tools and techniques for self-appraisal as part of the
process.
Conclusions: A multilayered adoption decision guide allows
users to select the appropriate level of detail while also
promoting evidence-based decision making. Such a tool
provides health care organizations of all types with a
framework for self-assessment in key financial, non-financial,
and strategic areas that should be considered before adopting
an innovation.
Implications for Policy, Practice or Delivery: Innovations to
improve health care continue to evolve. The use of a tool that
helps decision makers understand resistance to change, the
anticipated level of resources needed, and projected strategic
and operational costs involved may be pivotal in helping
organizations to optimize and operationalize improvements
systemwide.
Funding Source: AHRQ
ƒ Recruitment of Primary Care Clinics and Health Plans
under HIPAA Regulations
Eileen Emori, M.B.A. Management and Marketing, Amira ElBastawissi, M.B.Ch.B., Ph.D., Eric Ossiander, M.S.,
Biostatistics, Nguyet Tran, M.P.H., Doug Conrad, Ph.D.
Presented By: Eileen Emori, M.B.A. Management and
Marketing, Research Coordinator, Department of Health,
University of Washington & State of Washington, MS 47855,
Olympia, WA 98504-7855, Phone: (360) 236-3842, Fax: (360)
236-3708, Email: eileen.emori@doh.wa.gov
Research Objective: To develop effective methods for
recruiting clinics and health plans into a study to measure the
Washington State Collaborative's impact on diabetes patient
economic outcomes.
Study Design: We are recruiting 10 randomly selected WSC
clinics and 10 randomly selected (non-WSC participant)
control clinics. Non-WSC clinics are matched to WSC clinics
on clinic size (number of primary care providers). Clinic data
are being linked to health plan, hospital discharge, census,
and death certificate data. Clinic recruitment is sequential: 1.
Use the Internet to determine address, number of primary
care providers and contact information. 2. Call to confirm
contact and address of medical director or clinic
administrator. 3. Send invitation letter from the state health
officer to the contact. 4. Call contact and provide study
executive summary . 5. Arrange a face-to-face meeting with
contact. 6. Provide study materials: letter of support
template, data use agreement, patient selection criteria and
clinic questionnaire. 6. Use three additional follow-up calls
and two additional letters to promote the clinic’s participation.
Health plan recruitment entailed meetings with chief executive
officers, IRB committees, quality assurance/improvement
directors, IT directors, and data personnel. HIPAA regulations
required coordination with state health department quality
assurance, data security, contracts, and legal staff. We created
protocols, including data use agreements and data
specifications, to meet HIPAA, state and federal privacy rules.
Population Studied: Diabetes patients receiving care in
primary care clinics in Washington State.
Principle Findings: 1. WSC clinic participation rate is 62.5%
(10 of 16 clinics) and non-WSC clinic participation rate is 20%
(6 of 30 clinics contacted). Reasons for refusal include new
electronic medical records systems being set up in clinics,
clinic understaffing, clinic moving, clinic being too new to
have patient data from beginning of study period, and
specialty versus primary care clinic. 2. All 3 commercial health
plans and 1 public employee plan have agreed to participate. 3.
Costs to recruit: Average cost to recruit a clinic is $1,735 and
average cost to recruit a health plan is $2,160. Total cost for
recruitment of clinics is $34,700 and health plans is $8,640
including staff hours, travel and reimbursement to clinics and
health plans to offset organization-specific data collection
costs. Total recruitment cost to date is $43,340 over 6
months. 4. Security issues: We implemented special
procedures to meet HIPAA protected health information
(PHI) requirements. Meeting these requirements substantially
delayed receipt of clinic data. We could not allow an outside
contractor to analyze data off-site. We are creating ‘‘limited
data sets’’ (as defined by HIPAA) as analytic files.
Conclusions: Recruiting clinics and health plans requires
creative approaches to ensure data security at federal, state
and organizational levels of review. Data retrieval differs for
clinics and health plans, requiring tailored pre-planning, and
differential circumstances across organizations demand
flexible responses to staff turn-over, limited time and
resources.
Implications for Policy, Practice or Delivery: Especially in
complex, multi-level studies, researchers must craft flexible
recruitment, data collection, and data protection procedures
that reflect the diversity of organizations and environments
under study. This project's findings suggest a rigorous design
that meets those requirements and replicable by other
researchers.
Funding Source: RWJF
ƒ Trust Building among Minorities Through CBPR/Action
Research: Experiences from the Lower Mississippi Delta
Ari Mwachofi, Ph.D, Everlyn Bryant, Raw-Crop Farmer
Presented By: Ari Mwachofi, Ph.D, Assistant Professor,
Health Administration and Policy, OUHSC - College of Public
Health, 801 NE 13th Street, Oklahoma City, OK 73104, Phone:
(405) 271-2114, Fax: (405) 271-1868,
Email: amwachof@ouhsc.edu
Research Objective: The research purpose was to gather
service access and provision data for minority farmers and to
recommend a service access/provision model that would
improve minority farmers’ access. After applying the
traditional research approach and experiencing lack of trust,
building trust became a major objective of the study.
Study Design: The project applied the traditional research
approach with researcher hypotheses, methods, and survey
instruments developed outside the focus community.
Although the researchers were Black from a historically Black
university, Black farmers did not trust the researchers and
occasionally interviewers experienced open hostility. The
traditional research approach was replaced by CBPR/Action
Research. Farmers were included in re-planning the project.
They were trained as interviewers and focus group facilitators.
Their inclusion and participation was effective in building trust
as indicated by a dramatic improvement in response rates and
enthusiastic farmer participation in focus group.
Population Studied: Rural minorities in the lower Mississippi
Delta states Arkansas, Louisiana and Mississippi.
Principle Findings: CBPR/Action Research: facilitated trustbuilding; enhanced social capital as indicated by the creation
of a farmer-to-farmer support network; facilitated consumerservice provider dialogues; broadened the research focus and
activities; and facilitated a seamless translation of research
findings into practice as evidenced by changes in
rehabilitation services eligibility criteria to include more
farmers.
Conclusions: Rather than looking at minority health from the
outside, research should include insider information by
involving minority communities as powerful allies in research
and in the fight to end health disparities. CBPR/Action
Research is an effective tool in this focus shift.
Implications for Policy, Practice or Delivery: The new
approach requires a shift from looking at what should be done
to/for this population to what can be done in collaboration
with this population. This approach has two major elements
to this approach: i) Engagement rather than imposition which
shifts from the old paradigm of creating solutions outside and
imposing them on minority populations. This approach
engages and includes minority populations in all critical
phases to ensure that the created approach is born of the
minority population’s circumstances, it is homegrown,
relevant and acceptable to this population. Engagement of
the population becomes a catalyst to raising awareness and
encouraging action by the population, so that the intervention
creation is one with dissemination and application. It avoids
creating feelings of imposition, oppression and resentment
inherent in the old paradigm. This approach ‘‘roots live
interventions’’ in this population such that they are dynamic
amenable to changing with the conditions on the ground. It
also captures the power of collaboration and teamwork,
further catalyzing and strengthening positive changes. ii) New
Researcher Attitudes and Perspectives which requires the
awareness by academic researchers that they know less about
the conditions and experiences of the research subjects than
the subjects do. This is a difficult admission for researchers
who were trained in the old paradigm and who have
hypotheses that they want to prove/or disprove.
Funding Source: National Institute on Disability and
Rehabilitation Research (NIDRR)
ƒ Leveraging Front Line Expertise: A Safety Culture
Intervention to Enhance Senior Managers’ Engagement
Alyson Falwell, M.P.H., Sara Singer, M.B.A., Anita Tucker,
D.B.A., Alyson Falwell, M.P.H., Jennifer Hayes, M.A.
Presented By: Alyson Falwell, M.P.H., Center for Health
Policy/Primary Care and Outcomes Research, Stanford
University, 117 Encina Commons, Stanford, CA 94305, Phone:
(650) 724-0332, Fax: (650) 723-1919,
Email: falwell@stanford.edu
Research Objective: To allocate resources and intervene to
improve systems appropriately, senior managers must
accurately perceive the hazards experienced at the front lines
of healthcare delivery. Research, however, suggests that
executives are consistently more optimistic about their
organizations’ safety culture than frontline workers, and
workers’ perspectives are more accurate, i.e., they relate to
safety performance while executives’ perceptions do not. We
developed, implemented, and evaluated an intervention-----Leveraging Front Line Expertise (LFLE)------to engage hospital
executive teams in frontline care through a systematic process
that increased their availability in patient care work areas and
facilitated identification, prioritization, resolution, and
feedback about safety concerns. This project evaluates the
ability of hospitals to implement LFLE and reports qualitatively
on areas of success and quantitatively on characteristics of
hospitals associated with high achievement.
Study Design: We conducted LFLE in 24 U.S hospitals for 18
months beginning in 2005. In 3-month cycles, senior
managers completed the following activities in one hazardous
work area per cycle: 1) worksite observation; 2) safety forums
with frontline staff to identify and prioritize safety concerns; 3)
debrief meetings to propose resolutions and assign
responsibility; and 4) staff feedback. Hospitals documented
number of observations and forums, safety concerns
identified, resolutions recommended, and extent of
implementation. Prior to the intervention, we rated hospitals’
preparedness for and prioritization of the intervention based
on interviews and collected data on staff perceptions of safety
climate using the Patient Safety Climate in Healthcare
Organizations survey.
Population Studied: Self-identified teams of senior managers
(typically CEO, CMO, CNO, and Director of Quality/Patient
Safety) in 24 hospitals, participating in a study to measure
safety culture, and the frontline personnel and unit managers
in nearly 200 work areas visited. Hospitals were selected
using stratified random sampling techniques, and represent
all 4 U.S. census regions and 3 size categories.
Principle Findings: All hospitals successfully implemented
the intervention in at least one patient care area; 20 (83%)
completed two or more cycles, observing in 200 units and
conducting 50 forums. Over 1200 safety concerns------related
most often to communication and documentation,
equipment, infection control, and medication
administration------were identified by executives and frontline
staff. More than two-thirds of concerns identified were
addressed by improvements ranging from increased staffing
and staff development to procurement of goods or services
and equipment maintenance. Completion of improvement
cycles and identification and resolution of safety concerns
were more associated with the priority senior managers
granted to the intervention than with measures of hospital
safety climate strength or intervention preparedness scores.
Conclusions: A systematic intervention to expose senior
managers to the daily challenges faced by hospital staff helped
frontline workers speak up in ways that enabled executives to
hear and address their safety concerns. Executives rated the
intervention as valuable, and most plan to continue using the
methodology after the intervention period.
Implications for Policy, Practice or Delivery: Interventions
that expose senior managers to care ‘‘at the sharp end’’ can
improve communication about patient safety.
Funding Source: AHRQ
ƒ Facilitation in Implementing Evidence-Based Practices
for Schizophrenia: Researcher and Clinical Leader
Perspectives
Jeffrey Smith, Ph.D. Candidate, John J. Spollen, M.D., Richard
R. Owen, M.D.
Presented By: Jeffrey Smith, Ph.D. Candidate, Implementation
Research Coordinator, Central Arkansas Veterans Healthcare
System, VA Mental Health Quality Enhancement Research
Initiative, 2200 Fort Roots Drive, Building 58 (152/NLR), North
Little Rock, AR 72114, Phone: (501) 257-1066, Fax: (501) 2571707, Email: Jeffrey.Smith6@va.gov
Research Objective: ‘External facilitation’ is a technique used
by implementation researchers to work actively with clinical
stakeholders to enable the uptake of evidence into practice.
This abstract reports researcher and clinical leader
perspectives on external facilitation activities and lessons
learned in a Veterans Health Administration (VHA) Mental
Health Quality Enhancement Research Initiative (MH QUERI)
project to implement evidence-based antipsychotic
medication management for patients with schizophrenia.
Study Design: Descriptive case study of external facilitation
applied by researchers in partnership with VA medical center
staff implementing a team-based quality improvement (QI)
intervention, educational materials, and performance
monitoring tools to improve antipsychotic medication
management for patients with schizophrenia.
Population Studied: VA medical center mental health
clinicians
Principle Findings: The external facilitator maintained regular
contact with the QI team to monitor implementation of
project tools/strategies, identify barriers, problem-solve, and
assist in adapting tools/strategies as needed. Facilitation
resulted in placement of recommendations for antipsychotic
dosing and side effect monitoring on medication order
screens, enhanced performance reports tailored to clinician
preferences and specifications, and development of weekly
provider-specific reports identifying patients in need of
metabolic side effect monitoring. Side effect monitoring was
considerably improved subsequent to implementing the
weekly monitoring reports, moving the medical center from
non-compliance to compliance with network-level
performance measures for antipsychotic side effect
monitoring. Weekly reports continue to be utilized and
monitoring improvements have been sustained for one year
after the research project concluded. From the researcher
perspective, lessons learned include: (1) external facilitators
need to be flexible to accommodate suggestions of clinical
partners for modifying tools/strategies when initial efforts
have limited success, (2) rapid response to clinical partner
concerns is optimal but not always feasible due to
time/availability issues; and (3) there is a need to establish
boundaries for what facilitators will and will not do for clinical
partners to minimize potential for misunderstandings. From
the clinical leader perspective, external facilitation: (1) placed
too much initial emphasis on promoting provider education
strategies; and (2) encouraged innovation to emerge from
within the clinical team by actively eliciting and responding to
clinical staff feedback on needed refinements/augmentations
to intervention tools.
Conclusions: External facilitation as an implementation
strategy may foster collaborative relationships between
researchers and clinical leaders that can successfully
encourage the adoption and sustained use of evidence-based
practices.
Implications for Policy, Practice or Delivery: The process of
external facilitation may be a generalizable approach
researchers can use to implement evidence-based care in
routine clinical practice. New organizational structures or
mechanisms may be needed to support such research-clinical
partnerships.
Funding Source: VA