Using Implementation Science
to Effectively Implement
Evidence-Based Practices
Heather J. Gotham, PhD
Mid-America ATTC
UMKC School of Nursing
Health Literacy: A prescription for Patient
Engagement
February 12, 2013
“As clinicians,
what we say does not matter
unless patients are able to understand
the 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 if
we 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)
The Implementation Gap
Effective
Intervention
X
Ineffective or
Insufficient
Implementation
=
Inconsistent;
Not Sustainable;
Poor Outcomes
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
Weak
Implementation Implementation
(High Fidelity) (Low Fidelity)
ACT team
ACT team
Treatment Drop-outs
15%
30%
Substance Use in
Remission
55%
13%
Hospital Admissions
2.87
4.69
McHugo et al., 1999
The Implementation Gap in Healthcare
Patient
medication
adherence
Health
professional
adherence to
EBPs
Better
patient
health
What Works
INTERVENTION
IMPLEMENTATION
Effective
Effective
NOT Effective
Performance
Implementation
(High Fidelity)
Paper Implementation
Procedure Implementation
(Low Fidelity)
NOT Effective
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
Create a Successful Implementation
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
Implementation Drivers
Key elements of
capacity and
infrastructure that
influence a program’s
success
http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/
Implementation Drivers:
Training alone is never enough
Joyce and Showers (2002) study of implementing new education practices in the classroom
OUTCOMES
(% of Participants)
TRAINING
COMPONENTS
Theory and
Discussion
..+Demonstration in
Training
..+ Practice &
Feedback in Training
..+ Coaching in
Classroom
Knowledge
Skill
Demonstration
Use in the
Classroom
10%
5%
0%
30%
20%
0%
60%
60%
5%
95%
95%
95%
Implementation Drivers
STAFF
PERFORMANCE
EVALUATION
CONSULTATION
& COACHING
DECISION SUPPORT
DATA SYSTEMS
INTEGRATED &
COMPENSATORY
PRESERVICE
TRAINING
RECRUITMENT
AND SELECTION
FACILITATIVE
ADMINISTRATIVE
SUPPORTS
SYSTEMS
INTERVENTIONS
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 Steps
Implementation Team
1. Finalize Implementation Team
Recruitment/
Staff Selection
2.
Facil. Admin.
Supports
Decision
Support Data
Systems
Training
Meet every 2 weeks through March, then reevaluate
Screening Process
1. What is currently done?
Are nurses already doing EMR Screening?
EMR
1. Determine issues and system limits with EMR
What if only some items are completed?
Can all staff complete the screener?
Targeted training needed for all levels of staff
1. Education for nurses on all shifts
Staff
Person(s)
Deadline
Change
Agent
11/11
Team
11/18
Change
agent, head
nurse
11/18
Admin staff
with IT staff
11/15
initial
report
Health coach
supervisor
11/18
Comments
Completed
Review at
11/18
meeting
Improvement Cycles
Improvement cycles
and other quality
improvement
strategies help you to
manage the changes
being implemented
and to keep the focus
on what is working.
http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/
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
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.
http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/
Implementation Stages
Installation
•Acquire resources
•Assess needs
•Create
•Examine
implementation
innovations
plan
•Assess fit
•Develop
•Promote “buy in”
infrastructure
•Prepare staff
Exploration
Initial
Implementation
•Implementation
drivers
•Manage change &
expectations
•Improvement cycles
•Learn from mistakes
•Celebrate progress
Full
Implementation
•Implementation
drivers
•Monitor outcomes
•Improvement
cycles
•Components
integrated
•Fully functioning
•Sustainability
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