Section 2: Evidence implementation projects using an evidence-based audit and feedback approach: the JBI Implementation Framework

Abstract Background Central line-associated bloodstream infections (CLABSIs) result in approximately 28,000 deaths and approximately $2.3 billion in added costs to the U.S. healthcare system each year, and yet, many of these infections are preventable. At two large health systems in the southeast United States, CLABSIs continue to be an area of opportunity. Despite strong evidence for interventions to prevent CLABSI and reduce associated patient harm, such as use of chlorhexidine gluconate (CHG) bathing, the adoption of these interventions in practice is poor. The primary objective of this study was to assess the effect of a tailored, multifaceted implementation program on nursing staff’s compliance with the CHG bathing process and electronic health record (EHR) documentation in critically ill patients. The secondary objectives were to examine the (1) moderating effect of unit characteristics and cultural context, (2) intervention effect on nursing staff’s knowledge and perceptions of CHG bathing, and (3) intervention effect on CLABSI rates. Methods A stepped wedged cluster-randomized design was used with units clustered into 4 sequences; each sequence consecutively began the intervention over the course of 4 months. The Grol and Wensing Model of Implementation helped guide selection of the implementation strategies, which included educational outreach visits and audit and feedback. Compliance with the appropriate CHG bathing process and daily CHG bathing documentation were assessed. Outcomes were assessed 12 months after the intervention to assess for sustainability. Results Among the 14 clinical units participating, 8 were in a university hospital setting and 6 were in community hospital settings. CHG bathing process compliance and nursing staff’s knowledge and perceptions of CHG bathing significantly improved after the intervention (p = .009, p = .002, and p = .01, respectively). CHG bathing documentation compliance and CLABSI rates did not significantly improve; however, there was a clinically significant 27.4% decrease in CLABSI rates. Conclusions Using educational outreach visits and audit and feedback implementation strategies can improve adoption of evidence-based CHG bathing practices. Trial registration ClinicalTrials.gov, NCT03898115, Registered 28 March 2019.

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Evidence-Based and Clinical Outcome Scores to Facilitate Audit and Feedback for Colorectal Cancer Care

Diseases of the Colon & Rectum ◽

10.1007/dcr.0b013e31819edb7d ◽

2009 ◽

Vol 52 (4) ◽

pp. 616-622 ◽

Cited By ~ 9

Author(s):

Miriam R. Habib ◽

Michael J. Solomon ◽

Jane M. Young ◽

Bruce K. Armstrong ◽

Dianne O'Connell ◽

...

Keyword(s):

Colorectal Cancer ◽

Clinical Outcome ◽

Cancer Care ◽

Audit And Feedback ◽

Evidence Based ◽

Outcome Scores

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Evaluating the national multisite implementation of dialectical behaviour therapy in a community setting: A mixed methods approach

10.21203/rs.2.14353/v2 ◽

2019 ◽

Author(s):

Daniel Flynn ◽

Mary Joyce ◽

Conall Gillespie ◽

Mary Kells ◽

Michaela Swales ◽

...

Keyword(s):

Mixed Methods ◽

National Level ◽

Team Leader ◽

Barriers And Facilitators ◽

Future Research ◽

Evidence Based ◽

Community Settings ◽

Team Leaders ◽

Implementation Framework ◽

Mixed Methods Approach

Abstract Background The implementation of evidence-based interventions for borderline personality disorder in community settings is important given that individuals with this diagnosis are often extensive users of both inpatient and outpatient mental health services. Although work in this area is limited, previous studies have identified facilitators and barriers to successful DBT implementation. This study seeks to expand on previous work by evaluating a coordinated implementation of DBT in community settings at a national level. The Consolidated Framework for Implementation Research (CFIR) [1] provided structural guidance for this national level coordinated implementation.Methods A mixed methods approach was utilised to explore the national multi-site implementation of DBT from the perspective of team leaders and therapists who participated in the coordinated training and subsequent implementation of DBT. Qualitative interviews with DBT team leaders ( n = 8) explored their experiences of implementing DBT in their local service and was analysed using content analysis. Quantitative surveys from DBT therapists ( n = 74) examined their experience of multiple aspects of the implementation process including orienting the system, and preparations and support for implementation. Frequencies of responses were calculated. Written qualitative feedback was analysed using content analysis.Results Five themes were identified from the interview data: team formation, implementation preparation, client selection, service level challenges and team leader role. Participants identified team size and support for the team leader as key points for consideration in DBT implementation. Key challenges encountered were the lack of system support to facilitate phone coaching and a lack of allocated time to focus on DBT. Implementation facilitators included having dedicated team members and support from management.Conclusions The barriers and facilitators identified in this study are broadly similar to those reported in previous research. Barriers and facilitators were identified across several domains of the CFIR and are consistent with a recently published DBT implementation Framework [2]. Future research should pay particular attention to the domain of characteristics of individuals involved in DBT implementation. The results highlight the importance of a mandated service plan for the coordinated implementation of an evidence-based treatment in a public health service.

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Interactive Participatory Audit and Feedback (IPAF): Theory-based development and multi-site implementation outcomes with specialty clinic staff

10.21203/rs.3.rs-26043/v2 ◽

2020 ◽

Author(s):

Edmond Ramly ◽

Diane Lauver ◽

Andrea Gilmore-Bykovskyi ◽

Christie M Bartels

Keyword(s):

Risk Reduction ◽

Self Regulation ◽

Self Determination Theory ◽

Self Determination ◽

Audit And Feedback ◽

Evidence Based ◽

Cvd Risk ◽

Frontline Staff ◽

Target Behaviors ◽

Implementation Outcomes

Abstract Background: Theory-based implementation strategies, such as audit and feedback (A&F), can improve adoption of evidence-based practices. However, few strategies have been developed and tested to meet the needs of specialty clinics. In particular, frontline staff can execute CVD risk-reduction protocols, but A&F strategies to support them have not been well examined. Our objective was to develop and evaluate a novel A&F strategy, Interactive Participatory A&F (IPAF). Methods: We developed IPAF by combining theories to inform staff goals (Self-Regulation Theory) and address their psychological needs for relatedness, autonomy, and confidence (Self-Determination Theory). We facilitated IPAF fidelity by developing a theory-based facilitation tool: a semi-structured worksheet to guide flexible discussion of target behaviors, perceived barriers, goals, and action plans. We evaluated IPAF in the context of eight quasi-experimental implementations in specialty clinics across two health systems. Following a Hybrid Type 2 effectiveness-implementation design, we reported intervention outcomes for CVD risk-reduction elsewhere. This paper reports implementation outcomes associated with IPAF, focusing on feasibility, acceptability, fidelity, and adoption. We evaluated implementation outcomes using mixed-methods data including Electronic Health Records (EHR) data, team records, IPAF worksheets, and staff questionnaire responses. Results: Eighteen staff participated in 99 monthly, individual, synchronous (face-to-face or by phone) IPAF sessions during the first six months of implementation. Subsequently, we provided over 375 monthly feedback emails. Feasibility data revealed high staff attendance (90-93%) and engagement in IPAF sessions. Staff rated questionnaire items about acceptability of IPAF highly. IPAF records and staff responses demonstrated fidelity of delivery and receipt of IPAF. Adoption of target behaviors increased significantly (all P-values < 0.05) and was maintained for over 24 months. Conclusions: We developed and evaluated an interactive participatory A&F strategy with frontline staff in specialty clinics to improve implementation of evidence-based interventions. The IPAF toolkit combines two complementary theories: Self-Regulation Theory and Self-Determination Theory. Findings support feasibility, acceptability, and fidelity of IPAF, and staff adoption and maintenance of target behaviors. By evaluating multi-site implementation outcomes, we have extended prior research on clinic protocols and A&F beyond primary care settings and providers.

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Using implementation science to mitigate worsening health inequities in the United States during the COVID-19 pandemic

International Journal for Equity in Health ◽

10.1186/s12939-020-01293-2 ◽

2020 ◽

Vol 19 (1) ◽

Author(s):

Tyler A. Jacobson ◽

Lauren E. Smith ◽

Lisa R. Hirschhorn ◽

Mark D. Huffman

Keyword(s):

United States ◽

Community Engagement ◽

Implementation Research ◽

Policy Design ◽

Contextual Factors ◽

Health Inequities ◽

The United States ◽

Audit And Feedback ◽

Evidence Based ◽

Social Distancing

Abstract With the threat of coronavirus disease 2019 (Covid-19) enduring in the United States, effectively and equitably implementing testing, tracing, and self-isolation as key prevention and detection strategies remain critical to safely re-opening communities. As testing and tracing capacities increase, frameworks are needed to inform design and delivery to ensure their effective implementation and equitable distribution, and to strengthen community engagement in slowing and eventually stopping Covid-19 transmission. In this commentary, we highlight opportunities for integrating implementation research into planned and employed strategies in the United States to accelerate reach and effectiveness of interventions to more safely relax social distancing policies and open economies, schools, and other institutions. Implementation strategies, such as adapting evidence-based interventions based on contextual factors, promoting community engagement, and providing data audit and feedback on implementation outcomes, can support the translation of policies on testing, tracing, social distancing, and public mask use into reality. These data can demonstrate how interventions are put into practice and where adaptation in policy or practice is needed to respond to the needs of specific communities and socially vulnerable populations. Incorporating implementation research into Covid-19 policy design and translation into practice is urgently needed to mitigate the worsening health inequities in the pandemic toll and response. Applying rigorous implementation research frameworks and evaluation systems to the implementation of evidence-based interventions which are adapted to contextual factors can promote effective and equitable pandemic response and accelerate learning both among local stakeholders as well as between states to further inform their varied experiences and responses to the pandemic.

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Application of Monash Centre for Health Research and Implementation Framework to the Development of Polycycstic Ovary Syndrome Guideline: A Case Study on Implementation

Seminars in Reproductive Medicine ◽

10.1055/s-0038-1667311 ◽

2018 ◽

Vol 36 (01) ◽

pp. 013-018 ◽

Cited By ~ 5

Author(s):

Helen Skouteris ◽

Angela Melder ◽

Cate Bailey ◽

Heather Morris ◽

Rhonda Garad ◽

...

Keyword(s):

Knowledge Translation ◽

Health Research ◽

Stakeholder Engagement ◽

Scale Up ◽

Knowledge Generation ◽

Evidence Based ◽

Implementation Framework ◽

Variation In Care ◽

Underlying Principle

AbstractImplementation of healthcare guidelines, a set of recommendations aiming to optimize patient care, can be a complex process which is at risk of poor translation into practice. Failure to adopt new evidence-based healthcare findings can contribute to a large variation in care, potentially affecting outcomes for service users. Designed to avoid this issue, the Monash Centre for Health Research and Implementation (MCHRI) knowledge translation framework was created to support the development and future implementation of clinical practice guidelines. The framework is distinguished by a focus on methodological rigor, stakeholder engagement, and partnership, leading to the coproduction of a guideline and research projects. In this article, we use the development of the International Evidence-based Guideline on the Assessment and Management of Polycystic Ovarian Syndrome (2018) as a case study to articulate the MCHRI knowledge translation framework. Specifically, this article discusses stakeholder engagement; development and codesign of evidence-based recommendations; implementation and knowledge generation; dissemination, translation, and scale up; and refinement/learning from evaluation. This case study demonstrates how hybrid frameworks, models, and theories for implementation, such as the MCHRI implementation framework, have their place in healthcare. The underlying principle that informs the framework is stakeholder engagement, including codesign, empowerment, and partnership.

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The effectiveness of leadership: meta-analysis of trial, cross-sectional, and before after studies

European Journal of Public Health ◽

10.1093/eurpub/ckaa166.654 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

V Restivo ◽

M Gaeta ◽

A Odone ◽

C Trucchi ◽

A Battaglini ◽

...

Keyword(s):

Healthcare Workers ◽

Evidence Based Practice ◽

Meta Analysis ◽

Healthcare Setting ◽

Risk Difference ◽

Audit And Feedback ◽

Evidence Based ◽

Cross Sectional ◽

Cross Sectional Studies ◽

Private Setting

Abstract Background The clinical and surgical procedures are often based on scientifical evidence but 30-40% of patients do not receive treatment according to evidence based medicine. The main aim of this review and meta-analysis is to assess the effectiveness of leadership in healthcare setting. Methods It was conducted a literature research on MEDLINE, Pubmed and Scopus with publication year between 2015 and 2019. The inclusion criteria were studies involving healthcare workers that evaluated effectiveness of opinion leaders in improving behaviour of healthcare workers, according to clinical or patient related outcomes. The quality of studies were assesed with the NHLBI for before after studies and the NOS for other study designs. The effect of leadership was assessed as risk difference for all studies with the exception of cross sectional studies. For the last it was evaluated correlation between leadership level and outcome measurment. Results A total of 3,155 articles were screened and 284 were fully assessed including 22 of them in the final database: 1 randomized trial, 9 cross sectional and 12 before after studies. For the cross-sectional studies there was a correlation of 0.22 (95% CI 0.15-0.28) between leadership level and outcome measurment. In the metaregression analysis the only factor that increased the correlation was private setting (meta regression coefficent =0.52, p = 0.022). The pooled efficacy was 24% (95% CI 10%-17%) for before after studies. Furthermore, a higher effectiveness was revealed in studies conducted on multi professional (24%) than single professional (9%) healthcare workers. Conclusions According to results, the guidelines adherence and task performance increased in a setting with leadership implementation. The leadership effectiveness appears comparable to other strategies as audit and feedback used to implement evidence-based practice in worldwide healthcare. Key messages The translation of evidence into clinical practice is often difficult but this study suggests that leaderhip can had higher effectiveness in multiprofessional healthcare workers and private setting. The effectiveness of leadership in this review suggests that it can be of help in order to make aware healthcare professionals about effectiveness of comply with evidence-based practice.

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