Implementing Evidence-Base Practices: Be An EBP Know-It-All!! Brandeis U / Suffolk U: Educational Forum September 28, 2005 Wayne Stelk, Ph.D., VP, Quality Management Massachusetts Behavioral Health Partnership

Know: Your EBP Product

The Evidence Hierarchy I.Randomized controlled studies II.Scientifically sound experimental studies III.Level I or Level II practice modified and applied to a different population or in a different setting IV.Sound research, with documentation of service procedures and positive outcomes V.Practice not research-based or replicable

Practice Guideline Lower Fidelity Demands Practice Guideline –A clinical intervention typically developed through a formal process, based on authoritative “consensus” about the clinical literature – Intervention specifications are recommended, but the specific application of the intervention for the patient is at the discretion of the clinician

Evidence-Base Practice Higher Fidelity Demands Clinical intervention based upon rigorous research that shows positive outcomes consistently in repeated research studies The randomized clinical trial (RCT) is the “gold standard” of evidence As “manualized” treatment, clinicians must strictly adhere to all clinical standards as developed in the research protocol (fidelity)

What is a “Treatment Effect”?

Common Factors vs Specific Effects

Know: Your Audience

How Innovative Are We? Practice Guideline Usage Survey of BH Practitioners (N = 114) Heard about practice guidelines? –Psychiatrists: 94%; psychologists: 81%; social workers: 42% Inclined to use practice guidelines? –Psychiatrists: 88%; psychologists: 55%; social workers: 81% Aware of a particular guideline? –Psychiatrists: 88%; psychologists: 13%; social workers: 18% Actually used a practice guideline? –Psychiatrists: 64%; psychologists: 6%; social workers: 18% (Reference: Mullen and Bacon, 2005)

Clinician Characteristics/Effects (Mostly Ignored in Research Design) Objective Characteristics –Age, sex, ethnicity, socioeconomic background Cross-Situational Traits –Personality and coping patterns; emotional well-being; values, attitudes, beliefs; cultural attitudes Therapy-Specific States –Professional training; therapeutic style; choice of treatment interventions Clinician/Client Relationship –Therapeutic alliance; treatment expectations (Reference: Wampold, 2001, p. 185)

Know: Your EBP Implementation Strategy

What is Innovation Diffusion? Innovation = –An idea, practice, or object that is perceived as new to the individual or organization Diffusion = –The communication of an innovation through certain channels over time among members of a social system Innovation creates UNCERTAINTY Diffusion strategies must overcome uncertainty

Crossing the Chasm

Factors Affecting Rates of Innovation Adoption The attributes of the innovation (EBP) –(this factor explains 50% of the variance in the rate of adoption) Adopter (clinician) characteristics The communication channels (about which we don’t know much for clinicians) The social culture and structure (agencies) Extent of change agents’ promotion efforts

Factors Affecting Rate of Adoption Relative advantage of the EBP –Cost, status, incentives, mandates Compatibility (avoid “empty vessel” error) –Adopter values, beliefs, needs, professional training, indigenous knowledge Complexity –Negatively related to rate of adoption Triability –Positively related to rate of adoption Observability –The more observable the results, the better the rate of adoption Re-Invention –Positively related to rate of adoption (flies in the face of fidelity)

Stages in the Innovation-Decision Process (compared to Porchaska’s Stages-of-Change) Knowledge Stage (Precontemplation ) –Learn about requirements and necessary skills Persuasion Stage (Contemplation ) –Talk with others; form positive image; get peer support Decision Stage (Preparation) –Seek additional information; try it out Implementation Stage (Action) –Use innovation a regular basis Confirmation Stage (Maintenance) –Weigh advantages and benefits of continued use

What Are the Elements of a Good Implementation Strategy? Know that good EBP products will not sell themselves. Simplistic EBP implementation plans are not useful, such as Plan-Do-Check- Act. Implementation of EBPs is a complex task requiring: –Empirically-based planning; –A good product; –A good understanding of the adopter-clinician; Clinician characteristics Useful communication channels –A good understanding of organizational readiness for change; –A medium for implementing the EBP (who is the change agent?); and –Sufficient resources to build an EBP infrastructure to sustain and evaluate the new practices.

Final Thoughts EBPs have traction in the public arena. EBPs are stirring the pot in positive ways. EBPs may not be the perfect solution, but they have much to offer. We should be aware of both the upsides and downsides of EBPs. We should be aware of the challenges (and costs) of implementation. Massachusetts should be viewed as a leader in promoting and implementing EBPs.

References Mullen, E. J., & Bacon, W. (2004). Implementation of practice guidelines and evidence-based treatment: A survey of psychiatrists, psychologists, and social workers. In A. Roberts & K. Yeager (Eds.), Evidence-Based Practice Manual: Research and Outcome Measures in Health and human Services. New York: Oxford University Press. Rogers, E. (2003). Diffusion of Innovations (5th ed.). New York: Free Press. Wampold, B. E. (2001). The Great Psychotherapy Debate: Models, Methods, Findings. Mahway, NJ: Lawrence Erlbaum Associates.