scholarly journals Engaging Stakeholders to Retrospectively Discern Implementation Strategies in Support of Program Evaluation

2021 ◽  
Author(s):  
Jacob T. Painter ◽  
Rebecca A. Raciborski ◽  
Monica M. Matthieu ◽  
Ciara Oliver ◽  
David A. Adkins ◽  
...  
Keyword(s):  
Program Evaluation ◽  
Quality Improvement ◽  
Data Collection ◽  
Implementation Strategy ◽  
Implementation Strategies ◽  
Successful Implementation ◽  
Evidence Based ◽  
Main Body ◽  
Strategy Selection ◽  
Evidence Based Practices

Abstract Background: Successful implementation of evidence-based practices is key to healthcare quality improvement. However, it depends on appropriate selection of implementation strategies, the techniques that improve practice adoption or sustainment. When studying implementation of an evidence-based practice as part of a program evaluation, implementation scientists confront a challenge: the timing of strategy selection rarely aligns with the establishment of data collection protocols. Indeed, the exact implementation strategies used by an organization during a quality improvement initiative may be determined during implementation. Nevertheless, discernment of strategies is necessary to accurately estimate implementation effect and cost because this information can support decision making for sustainment, guide replication efforts, and inform the choice of implementation strategies for other evidence-based practices. Main body: We propose an iterative, stakeholder engaged process to discern implementation strategies when strategy choice was not made before data collection began. Stakeholders are centered in the process, providing a list of current and potential implementation activities. These activities are then mapped by an implementation science expert to an established taxonomy of implementation strategies. The mapping is then presented back to stakeholders for member checking and refinement. The final list can be used to survey those engaged in implementation activities in a language they are familiar with. A case study using this process is provided. Conclusion: It is challenging to estimate implementation effort when implementation strategy selection is disconnected from the data collection process. In these cases, a stakeholder-informed process to retrospectively identify implementation strategies by classifying activities performed using an established implementation strategy taxonomy provides the necessary information.

scholarly journals Training registered nurses to conduct pre-implementation assessment to inform program scale-up: an example from the rural Transitions Nurse Program

2021 ◽  
Vol 2 (1) ◽  
Author(s):  
Chelsea Leonard ◽  
Heather Gilmartin ◽  
Marina McCreight ◽  
Lynette Kelley ◽  
Ashlea Mayberry ◽  
...  
Keyword(s):  
Data Collection ◽  
Implementation Strategy ◽  
Care Transitions ◽  
Scale Up ◽  
Barriers And Facilitators ◽  
Local Context ◽  
Successful Implementation ◽  
Evidence Based ◽  
Local Contexts ◽  
Implementation Assessment

Abstract Objectives Adapting evidence-based practices to local settings is critical for successful implementation and dissemination. A pre-implementation assessment evaluates local context to inform implementation, but there is little published guidance for clinician-implementers. The rural Transitions Nurse Program (TNP) is a care coordination intervention that facilitates care transitions for rural veterans. In year 1 of TNP, pre-implementation assessments were conducted by a centralized project team through multi-day visits at five sites nationwide. In year 2, we tested if local site TNP nurses could conduct pre-implementation assessments using evidence-based tools and coaching from the TNP team. This required developing a multicomponent pre-implementation strategy bundle to guide data collection and synthesis. We hypothesized that (1) nurses would find the pre-implementation assessment useful for tailoring TNP to local contexts and (2) nurses would identify similar barriers and facilitators to those identified at first year sites. Methods The bundle included guides for conducting key informant interviews, brainwriting, process mapping, and reflective journaling. We evaluated TNP nurse satisfaction and perceived utility of the structure and process of the training and bundle through pre-post surveys. To assess the outcome of data collection efforts, we interviewed nurses 4 months after completion of the pre-implementation assessment to determine if and how they used pre-implementation findings to tailor implementation of TNP to local contexts. To further assess outcomes, all data that the nurses collected were analyzed thematically. Themes related to barriers and facilitators were compared across years. Findings Five nurses at different VA medical centers used the pre-implementation strategy bundle to collect site-level data and completed pre-post surveys. Findings indicated that the pre-implementation assessment was highly recommended, and the bundle provided adequate training. Nurses felt that pre-implementation work oriented them to the local context and illustrated how to integrate TNP into existing processes. Barriers and facilitators identified by nurses were similar to those collected in year 1 by the TNP research team, including communication challenges, need for buy-in, and logistical concerns. Conclusions This proof-of-concept study suggests that evidence-based tools can effectively guide clinician-implementers through the process of conducting a pre-implementation assessment. This approach positively informed TNP implementation and oriented nurses to their local context prior to implementation.

scholarly journals Transforming Mental Health Delivery Through Behavioral Economics and Implementation Science: Protocol for Three Exploratory Projects (Preprint)

2018 ◽  
Author(s):  
Rinad S Beidas ◽  
Kevin G Volpp ◽  
Alison N Buttenheim ◽  
Steven C Marcus ◽  
Mark Olfson ◽  
...  
Keyword(s):  
Mental Health ◽  
Decision Making ◽  
Data Collection ◽  
Behavioral Economics ◽  
Psychiatric Disorders ◽  
Implementation Science ◽  
Participatory Design ◽  
Implementation Strategies ◽  
Successful Implementation ◽  
Evidence Based

BACKGROUND Efficacious psychiatric treatments are not consistently deployed in community practice, and clinical outcomes are attenuated compared with those achieved in clinical trials. A major focus for mental health services research is to develop effective and cost-effective strategies that increase the use of evidence-based assessment, prevention, and treatment approaches in community settings. OBJECTIVE The goal of this program of research is to apply insights from behavioral economics and participatory design to advance the science and practice of implementing evidence-based practice (EBP) for individuals with psychiatric disorders across the life span. METHODS Project 1 (Assisting Depressed Adults in Primary care Treatment [ADAPT]) is patient-focused and leverages decision-making heuristics to compare ways to incentivize adherence to antidepressant medications in the first 6 weeks of treatment among adults newly diagnosed with depression. Project 2 (App for Strengthening Services In Specialized Therapeutic Support [ASSISTS]) is provider-focused and utilizes normative pressure and social status to increase data collection among community mental health workers treating children with autism. Project 3 (Motivating Outpatient Therapists to Implement: Valuing a Team Effort [MOTIVATE]) explores how participatory design can be used to design organizational-level implementation strategies to increase clinician use of EBPs. The projects are supported by a Methods Core that provides expertise in implementation science, behavioral economics, participatory design, measurement, and associated statistical approaches. RESULTS Enrollment for project ADAPT started in 2018; results are expected in 2020. Enrollment for project ASSISTS will begin in 2019; results are expected in 2021. Enrollment for project MOTIVATE started in 2018; results are expected in 2019. Data collection had begun for ADAPT and MOTIVATE when this protocol was submitted. CONCLUSIONS This research will advance the science of implementation through efforts to improve implementation strategy design, measurement, and statistical methods. First, we will test and refine approaches to collaboratively design implementation strategies with stakeholders (eg, discrete choice experiments and innovation tournaments). Second, we will refine the measurement of mechanisms related to heuristics used in decision making. Third, we will develop new ways to test mechanisms in multilevel implementation trials. This trifecta, coupled with findings from our 3 exploratory projects, will lead to improvements in our knowledge of what causes successful implementation, what variables moderate and mediate the effects of those causal factors, and how best to leverage this knowledge to increase the quality of care for people with psychiatric disorders. CLINICALTRIAL ClinicalTrials.gov NCT03441399; https://www.clinicaltrials.gov/ct2/show/NCT03441399 (Archived by WebCite at http://www.webcitation.org/74dRbonBD) INTERNATIONAL REGISTERED REPOR DERR1-10.2196/12121

scholarly journals Getting to implementation: a protocol for a Hybrid III stepped wedge cluster randomized evaluation of using data-driven implementation strategies to improve cirrhosis care for Veterans

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Shari S. Rogal ◽  
Vera Yakovchenko ◽  
Timothy Morgan ◽  
Jasmohan S. Bajaj ◽  
Rachel Gonzalez ◽  
...  
Keyword(s):  
Implementation Strategies ◽  
Data Driven ◽  
Successful Implementation ◽  
Evidence Based ◽  
Implementation Intervention ◽  
Health Administration ◽  
Stepped Wedge ◽  
Evidence Based Practices ◽  
Using Data ◽  
Cluster Randomized

Abstract Background Cirrhosis is a rapidly increasing cause of global mortality. To improve cirrhosis care, the Veterans Health Administration (VHA) developed the Hepatic Innovation Team (HIT) Collaborative to support VA Medical Centers (VAMCs) to deliver evidence-based cirrhosis care. This randomized HIT program evaluation aims to develop and assess a novel approach for choosing and applying implementation strategies to improve the quality of cirrhosis care. Methods Evaluation aims are to (1) empirically determine which combinations of implementation strategies are associated with successful implementation of evidence-based practices (EBPs) for Veterans with cirrhosis, (2) manualize these “data-driven” implementation strategies, and (3) assess the effectiveness of data-driven implementation strategies in increasing cirrhosis EBP uptake. Aim 1 will include an online survey of all VAMCs’ use of 73 implementations strategies to improve cirrhosis care, as defined by the Expert Recommendations for Implementing Change taxonomy. Traditional statistical as well as configurational comparative methods will both be employed to determine which combinations of implementation strategies are associated with site-level adherence to EBPs for cirrhosis. In aim 2, semi-structured interviews with high-performing VAMCs will be conducted to operationalize successful implementation strategies for cirrhosis care. These data will be used to inform the creation of a step-by-step guide to tailoring and applying the implementation strategies identified in aim 1. In aim 3, this manualized implementation intervention will be assessed using a hybrid type III stepped-wedge cluster randomized design. This evaluation will be conducted in 12 VAMCs, with four VAMCs crossing from control to intervention every 6 months, in order to assess the effectiveness of using data-driven implementation strategies to improve guideline-concordant cirrhosis care. Discussion Successful completion of this innovative evaluation will establish the feasibility of using early evaluation data to inform a manualized, user-friendly implementation intervention for VAMCs with opportunities to improve care. This evaluation will provide implementation support tools that can be applied to enhance the implementation of other evidence-based practices. Trial registration This project was registered at ClinicalTrials.Gov (NCT04178096) on 4/29/20.

scholarly journals Virtual external implementation facilitation: successful methods for remotely engaging groups in quality improvement

2021 ◽  
Vol 2 (1) ◽  
Author(s):  
Christine W. Hartmann ◽  
Ryann L. Engle ◽  
Camilla B. Pimentel ◽  
Whitney L. Mills ◽  
Valerie A. Clark ◽  
...  
Keyword(s):  
Public Health ◽  
Quality Improvement ◽  
Evidence Based ◽  
National Program ◽  
Extensive Experience ◽  
Evidence Based Practices ◽  
Team Members ◽  
Virtual Experience ◽  
Key Points ◽  
Program Content

Abstract Background Relatively little guidance exists on how to use virtual implementation facilitation to successfully implement evidence-based practices and innovations into clinical programs. Yet virtual methods are increasingly common. They have potentially wider reach, emergent public health situations necessitate their use, and restrictions on resources can make them more attractive. We therefore outline a set of principles for virtual external implementation facilitation and a series of recommendations based on extensive experience successfully using virtual external implementation facilitation in a national program. Model and recommendations Success in virtual external implementation facilitation may be achieved by facilitators applying three overarching principles: pilot everything, incorporate a model, and prioritize metacognition. Five practical principles also help: plan in advance, communicate in real time, build relationships, engage participants, and construct a virtual room for participants. We present eight concrete suggestions for enacting the practical principles: (1) assign key facilitation roles to facilitation team members to ensure the program runs smoothly; (2) create small cohorts of participants so they can have meaningful interactions; (3) provide clarity and structure for all participant interactions; (4) structure program content to ensure key points are described, reinforced, and practiced; (5) use visuals to supplement audio content; (6) build activities into the agenda that enable participants to immediately apply knowledge at their own sites, separate from the virtual experience; (7) create backup plans whenever possible; and (8) engage all participants in the program. Summary These principles represent a novel conceptualization of virtual external implementation facilitation, giving structure to a process that has been, to date, inadequately described. The associated actions are demonstrably useful in supporting the principles and offer teams interested in virtual external implementation facilitation concrete methods by which to ensure success. Our examples stem from experiences in healthcare. But the principles can, in theory, be applied to virtual external implementation facilitation regardless of setting, as they and the associated actions are not setting specific.

scholarly journals Developing implementation strategies to adopt Enhanced Recovery After Surgery (ERAS®) guidelines

BJS Open ◽  
2020 ◽  
Vol 5 (2) ◽  
Author(s):  
Jennifer Y Lam ◽  
Alexandra Howlett ◽  
Duncan McLuckie ◽  
Lori M Stephen ◽  
Scott D N Else ◽  
...  
Keyword(s):  
Implementation Strategy ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Healthcare Providers ◽  
Implementation Strategies ◽  
Multidisciplinary Teams ◽  
Successful Implementation ◽  
Care Pathways ◽  
Audit System ◽  
Local Contexts

Abstract Background Strong implementation strategies are critical to the success of Enhanced Recovery after Surgery (ERAS®) guidelines, though little documentation exists on effective strategies, especially in complex clinical situations and unfamiliar contexts. This study outlines the process taken to adopt a novel neonatal ERAS® guideline. Methods The implementation strategy was approached in a multi-pronged, concurrent but asynchronous fashion. Between September 2019 and January 2020, healthcare providers from various disciplines and different specialties as well as parents participated in the strategy. Multidisciplinary teams were created to consider existing literature and local contexts including potential facilitators and/or barriers. Task forces worked collaboratively to develop new care pathways. An audit system was developed to record outcomes and elicit feedback for revision. Results 32 healthcare providers representing 9 disciplines and 5 specialties as well as 8 parents participated. Care pathways and resources were created. Elements recommended for a successful implementation strategy included identification of champions, multidisciplinary stakeholder involvement, consideration of local contexts and insights, patient/family engagement, education, and creation of an audit system. Conclusion A multidisciplinary and structured process following principles of implementation science was used to develop an effective implementation strategy for initiating ERAS® guidelines.

scholarly journals Implementation of a Quality Improvement Role for Unlicensed Assistive Personnel and Effects on Infection Prevention

2021 ◽  
Vol 1 (S1) ◽  
pp. s73-s74
Author(s):  
Natalie Schnell ◽  
Lauren DiBiase ◽  
Amy Selimos ◽  
Lisa Stancill ◽  
Shelley Summerlin-Long ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Data Collection ◽  
Patient Care ◽  
Patient Outcomes ◽  
Infection Prevention ◽  
Central Line ◽  
Direct Patient Care ◽  
Evidence Based ◽  
Infection Rates ◽  
Process Measure

Background: Care bundles comprise evidence-based practices and interventions that are easily and consistently implemented while improving patient outcomes. As patient acuity and task overload continue to increase, infection prevention bundle and process measure compliance and data collection may become a lower priority for registered nurses (RNs). In early 2019, a certified nursing assistant (CNA) began full-time quality liaison work on a 53-bed inpatient adult oncology unit at UNC Medical Center to provide targeted compliance data collection and to correct deficits in real time when possible and within the appropriate scope of practice. Methods: The quality liaison CNA is highly motivated, with a relevant clinical background and effective communication skills. After conducting a gap analysis, the unit developed specific responsibilities for several areas of quality improvement, including infection prevention. In addition to rounding on all patients daily, the quality liaison (1) performs direct patient care tasks like Foley catheter care, (2) conducts patient education on topics such as chlorhexidine gluconate treatments, (3) performs all relevant process measure audits, and (4) easily relays missed or needed care to RNs with a door sign created as part of this initiative. High-risk findings, such as a loose central-line dressing, prompt immediate communication to the RN, with follow-up and escalation when necessary. Results: Patients and staff received the quality liaison well, and the increased attention to care bundle components and auditing ensured consistent, evidence-based care along with accurate and reliable data collection. Compared to the previous calendar year, the number of central-line audits on the unit increased by >1,400 by the end of 2019. Patient outcomes improved, and during 1 fiscal year, the unit achieved rate reductions between 40% and 55% for central-line–associated bloodstream infections, catheter-associated urinary tract infections, and healthcare-associated C. difficile infections. Staffing and logistical challenges imposed by the COVID-19 global pandemic have hampered this work because the quality liaison was redeployed to direct patient care intermittently. Correspondingly, from July to October 2020, the same infection rates increased between 30% and 353%. Conclusions: Having a designated quality liaison is an effective means to achieving quality improvements while remaining an integral member of the patient care team. As staffing has improved on this unit, the quality liaison has refocused efforts, and infection rates are beginning to improve. Given the success of the quality liaison role in improving quality outcomes on this unit, the hospital is exploring expansion of this model to additional units.Funding: NoDisclosures: None

scholarly journals Planning Implementation Success of Syncope Clinical Practice Guidelines in the Emergency Department Using CFIR Framework

2021 ◽  
Author(s):  
Jing Li ◽  
Susan S. Smyth ◽  
Jessica Miller Clouser ◽  
Colleen A. McMullen ◽  
Vedant Gupta ◽  
...  
Keyword(s):  
Emergency Department ◽  
Clinical Practice ◽  
Family Caregivers ◽  
Implementation Strategy ◽  
Care Pathway ◽  
Implementation Strategies ◽  
Mobile App ◽  
Care Plan ◽  
Local Context ◽  
Successful Implementation

Background and Objectives: Overuse and inappropriate use of testing and hospital admission are common in syncope evaluation and management. Though guidelines are available to optimize syncope care, study suggested that the current clinical guidelines have not significantly impacted resource utilization surrounding emergency department (ED) evaluation of syncope. Matching implementation strategies to barriers and facilitators and tailoring strategies to local context hold significant promise for a successful implementation of clinical practice guideline (CPG). Our team applied implementation science principles to develop a stakeholder-based implementation strategy. Methods and Materials: We partnered with patients, family caregivers, frontline clinicians and staff, and health system administrators at four health systems to conduct quantitative surveys and qualitative interviews for context assessment. The identification of implementation strategies was done by applying the CFIR-ERIC Implementation Strategy Matching Tool and soliciting stakeholders’ inputs. We then co-designed with patients and frontline teams, developed and tested specific strategies. Results: 114 clinicians completed surveys and 32 clinicians and stake-holders participated in interviews. Results from the surveys and interview indicated low awareness of syncope guidelines, and communication challenges with patients, lack of CPG protocol integration into ED workflows, and organizational process to change were recognized as major barriers. Thirty-one patients and their family caregivers participated in interviews and ex-pressed their expectations: clarity regarding their diagnosis, context surrounding care plan and diagnostic testing, and a desire to feel cared about. After identifying change methods to address those barriers, the multilevel, multicomponent implementation strategy, MISSION, included pa-tient educational materials, mentored implementation, academic detailing, Syncope Optimal Care Pathway and corresponding Mobile App, and Lean quality improvement methods. The pilot of MISSION demonstrated feasibility, acceptability and initial success on appropriate testing. Con-clusions: Effect multifaceted implementation strategies that target individuals, teams, and healthcare systems can be employed to plan successful implementation and promote adherence to syncope CPGs.

scholarly journals Harmonizing evidence-based practice, implementation context, and implementation strategies with user-centered design: a case example in young adult cancer care

2020 ◽  
Author(s):  
Emily R Haines ◽  
Alex Dopp ◽  
Aaron R. Lyon ◽  
Holly O. Witteman ◽  
Miriam Bender ◽  
...  
Keyword(s):  
Young Adult ◽  
Outcome Measure ◽  
Implementation Strategies ◽  
Patient Reported Outcome ◽  
Evidence Based ◽  
User Centered Design ◽  
Evidence Based Practices ◽  
Patient Reported Outcome Measure ◽  
Patient Reported ◽  
User Centered

Abstract Background. Attempting to implement evidence-based practices in contexts for which they are not well-suited may compromise their fidelity and effectiveness or burden users (e.g., patients, providers, healthcare organizations) with elaborate strategies intended to force implementation. To improve the fit between evidence-based practices and contexts, implementation science experts have called for methods for adapting evidence-based practices and contexts, and tailoring implementation strategies; yet, methods for considering the dynamic interplay among evidence-based practices, contexts, and implementation strategies remain lacking. We argue that harmonizing the three can be accomplished with User-Centered Design, an iterative and highly stakeholder-engaged set of principles and methods. Methods. This paper presents a case example in which we used User-Centered Design methods and a three-phase User-Centered Design process to design a care coordination intervention for young adults with cancer. Specifically, we used usability testing to redesign an existing evidence-based practice (i.e., patient-reported outcome measure that served as the basis for intervention) to optimize usability and usefulness, an ethnographic user and contextual inquiry to prepare the context (i.e., comprehensive cancer center) to promote receptivity to implementation, and iterative prototyping workshops with a multidisciplinary design team to design the care coordination intervention and anticipate implementation strategies needed to enhance contextual fit. Results. Our User-Centered Design process resulted in the Young Adult Needs Assessment and Service Bridge (NA-SB), including a patient-reported outcome measure redesigned to promote usability and usefulness and a protocol for its implementation. By ensuring NA-SB directly responded to features of users and context, we designed NA-SB for implementation , potentially minimizing the strategies needed to address misalignment that may have otherwise existed. Furthermore, we designed NA-SB for scale-up ; by engaging users from other cancer programs across the country to identify points of contextual variation which would require flexibility in delivery, we created a tool not overly tailored to one unique context. Conclusions. User-Centered Design can help maximize usability and usefulness when designing evidence-based practices, preparing contexts, and informing implementation strategies- in effect, harmonizing evidence-based practices, contexts, and implementation strategies to promote implementation and effectiveness.

Senior staff perspectives of a quality indicator program in public sector residential aged care services: a qualitative cross-sectional study in Victoria, Australia

2016 ◽  
Vol 40 (1) ◽  
pp. 54 ◽  
Author(s):  
Liam M. Chadwick ◽  
Aleece MacPhail ◽  
Joseph E. Ibrahim ◽  
Linda McAuliffe ◽  
Susan Koch ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Public Sector ◽  
Data Collection ◽  
Aged Care ◽  
Residential Aged Care ◽  
Successful Implementation ◽  
Front Line ◽  
Cross Sectional ◽  
Executive Staff ◽  
Care Services

Objective The aims of the present study were to describe the views of senior clinical and executive staff employed in public sector residential aged care services (RACS) about the benefits and limitations of using quality indicators (QIs) for improving care, and to identify any barriers or enablers to implementing the QI program. Methods A cross-sectional qualitative study using semistructured interviews and direct observation of key informants involved in the QI program was performed across 20 public sector RACS in Victoria, Australia. Participants included senior clinical, executive and front-line staff at the RACS. The main outcome measures were perceived benefits and the enablers or barriers to the implementation of a QI program. Results Most senior clinical and executive staff respondents reported substantive benefits to using the QIs and the QI program. A limited number of staff believed that the QI program failed to improve the quality of care and that the resource requirements outweighed the benefits of the program, resulting in disaffected staff. Conclusions The QIs and QI program acted as a foundation for improving standards of care when used at the front line or point of care. Senior executive engagement in the QI program was vital to successful implementation. What is known about this topic? QIs measure the structures, processes or outcomes of care and identify issues that need further investigation or improvement. QIs are increasingly being adopted throughout the world. In Australia, the public sector RACS QIs project was implemented in 2006. It is yet to be formally evaluated. What does this paper add? Perceived benefits and limitations of the QI program were identified, together with barriers to successful implementation of the program and recommendations for future improvements. QI data were reported to improve quality culture and assist with identifying clinical areas for improvement. However, the QI program was associated with significantly increased workload and some stakeholders questioned its usefulness. The QI program studied could be improved through better access to education and training for those responsible for data collection and results dissemination to appropriate training and resources; and revision of the QI definitions and reporting methods. What are the implications for clinicians? QI data are useful for identifying opportunities for quality improvement. Despite data limitations, public sector RACS can use data for internal benchmarking, staff education and targeting of quality improvement interventions. At the policy level, revising the QI definitions and simplifying data collection and reporting would improve and strengthen the program. At the clinician and executive level, there is also a strong preference for QI data that allow comparison and benchmarking between facilities.

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