Presentation on theme: "Heather J. Gotham, PhD Mid-America ATTC UMKC School of Nursing"— Presentation transcript:
1 Using Implementation Science to Effectively Implement Evidence-Based Practices Heather J. Gotham, PhDMid-America ATTCUMKC School of NursingHealth Literacy: A prescription for Patient EngagementFebruary 12, 2013
2 what we say does not matter unless patients are able to understand “As clinicians,what we say does not matterunless patients are able to understandthe 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 ifwe didn’t treat them.”United States Surgeon General; Benjamin, 2010
3 Objectives Define implementation and implementation science Describe the implementation gap and its effects on evidence-based practicesDescribe 4 strategies from implementation science research to assist with organizational changes and promote the best patient outcomes
4 What I want to focus on is the intersection between your strategy or evidence based practice, and its implementation or getting the practice to actually be used in your clinic.4
5 ATTC Technology Transfer Workgroup, 2010 ImplementationIncorporating 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).This stage in the process in which the innovation is integrated into everyday practice.Involves a range of strategies and actions that are designed to address the integration of the innovation. Implementation efforts should be specific to individuals, organization and systems.Some examples of how to aide in implementation efforts: specific trainings and skill building exercises on the innovation; eliciting administrative buy-in and support; involving all stakeholders at multiple levels within an organization and making policy changes to support the implementation of the innovation.ATTC Technology Transfer Workgroup, 2010
6 Implementation Science Combines research across fieldsRural sociologyMedical sociologyCommunication & marketingEvidence-based medicineOrganizational changeStudies how evidence-based practices are used in the real worldStudies what strategies can help most efficiently implement evidence-based practicesGreenhalgh et al., 2004
7 Grei“Passive approaches are generally ineffective and unlikely to result in behavior change.” (Grimshaw 2001)What we used to do is assume that once you had a strategy, you were done.Most efforts to get physicians and healthcare professionals to change to more evidence-based practices relied on mailing them practice guidelines or treatment manuals.Through implementation science studies, we know that most mailed-out guidelines ended up in piles on desks.Grimshaw 2001 – summary of 41 reviews about changing health provider behavior: “passive approaches are generally ineffective and unlikely to result in behavior change.”
8 “Train and hope” doesn’t work either. (Stilen 2013) We also know that one or two-day trainings don’t work. Continuing education generally is just good for awareness raising and building knowledge, not changing skills or practice.“Train and hope” doesn’t work either. (Stilen 2013)
9 The Implementation Gap EffectiveInterventionIneffective orInsufficientImplementationInconsistent;Not Sustainable;Poor OutcomesX=So, we have an implementation gap, where we have effective interventions, but if attention isn’t paid to how they’re implemented, then those interventions do not result in positive outcomes for patients.
10 Assertive Community Treatment Patients with mental health and substance use disordersTreatment using multi-disciplinary teamStrong Implementation (High Fidelity) ACT teamWeak Implementation (Low Fidelity) ACT teamTreatment Drop-outs15%30%Substance Use in Remission55%13%Hospital Admissions2.874.69Here’s one specific example, showing that lack of attention to how an effective treatment is implemented, leads to negative outcomes for patients.The slide reviews a study by Gregory McHugo and colleagues on Assertive Community Treatment (ACT) and shows that treatment fidelity impacts outcomes.If you implement an EBP or innovation without fidelity to the original model, then the treatment will not work as well as in the original research.McHugo et al., 199910
11 The Implementation Gap in Healthcare PatientmedicationadherenceBetterpatienthealthHealthprofessionaladherence toEBPsSo, just as we know that if patients don’t adhere to their medication, they will have negative outcomes,If we as health professionals don’t adhere to evidence-based practices, including practices related to health literacy, and implement them carefully, our patients will not have positive outcomes.
13 Difficult to Change Practice and Make it Stick (Routine)
14 Use Implementation Science to Create Successful Change
15 Create a Successful Implementation Team Organizational SponsorLeads implementation effort, appoints the Change AgentActs as a mentor to maintain enthusiasmProblem-solver, assists Change Agent and Team
16 Create a Successful Implementation Team Change AgentOverall responsibility for implementation and planSupervisory position with responsibility and authority to implement policy and programmatic changesRecognized/respected for leadership, organizational savvy, and persistence
17 Create a Successful Implementation Team Comprised of staff from all levels/rolesAdministrative, Supervisory, Support, Technical and/or ITPatientsMeet regularlyReview implementation planning
18 Implementation Drivers Key elements of capacity and infrastructure that influence a program’s success
19 Implementation Drivers: Training alone is never enough Joyce and Showers (2002) study of implementing new education practices in the classroom OUTCOMES(% of Participants)TRAININGCOMPONENTSKnowledgeSkillDemonstrationUse in the ClassroomTheory and Discussion10%5%0%..+Demonstration in Training30%20%..+ Practice & Feedback in Training60%..+ Coaching in Classroom95%
20 Must be addressed for successful implementation Implementation DriversINTEGRATED & COMPENSATORYCONSULTATION & COACHINGSTAFF PERFORMANCEEVALUATIONFACILITATIVE ADMINISTRATIVE SUPPORTSRECRUITMENT AND SELECTIONPRESERVICE TRAININGSYSTEMSINTERVENTIONSDECISION SUPPORT DATA SYSTEMSMust be addressed for successful implementationImplementation Research, Fixsen et al., 2005;
21 Implementation Driver Use Implementation Drivers toDevelop an Implementation PlanImplementation Driver Implementation StepsStaff Person(s)DeadlineCommentsRecruitment/ Staff SelectionImplementation TeamFinalize Implementation TeamChange Agent11/11CompletedMeet every 2 weeks through March, then re-evaluateTeam11/18Facil. Admin. SupportsScreening ProcessWhat is currently done?Are nurses already doing EMR Screening?Change agent, head nurseDecision Support Data SystemsEMRDetermine issues and system limits with EMRWhat if only some items are completed?Can all staff complete the screener?Admin staff with IT staff11/15 initial reportReview at 11/18 meeting TrainingTargeted training needed for all levels of staffEducation for nurses on all shiftsHealth coach supervisor
22 Improvement CyclesImprovement cycles and other quality improvement strategies help you to manage the changes being implemented and to keep the focus on what is working.
23 Improvement Cycles Plan: Plan the change using the implementation plan Do: Make the changeStudy: Evaluate what happenedAct: Continue or go back toplanning
24 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.
26 Use Implementation Science to Create Successful Change TeamsBuild an implementation teamDriversTraining alone is never enoughDetailed implementation planImprovement CyclesPDSA cyclesStagesImplementing new practices takes months to yearsRecognize the change process
28 Five warning signs for De-adoption of EBPs Massatti et al., 2008
29 Lack of ongoing resources Massatti et al., 2008
30 Lack of support from external groups of the effort to change Massatti et al., 2008
31 Attitudes about the new practice – think we do it already versus open to learning and changing Massatti et al., 2008
32 Beliefs that the new practice does not fit with our knowledge/skills or the agency’s mission/philosophyMassatti et al., 2008
33 Beliefs that the new practice is neither easy to implement nor a permanent part of the agency’s servicesMassatti et al., 2008
34 SustainabilityPlan for sustainability as you’re writing the grant/planning the projectPrepare for turnoverDevelop expertise in the agencyWhat are your re-training plans?Plan for continued resources where neededOutcome data/continuous quality improvementFinally, a program or agency can move into a sustainability stage where further resources, supervision, and training are required to continue long-term use of the practice or assessment.
35 ContactHeather J. Gotham, PhD Associate Research Professor Mid-America ATTC UMKC School of Nursing direct (816)