1. Documenting Adaptations in the triple aim Queri Projects: Tracking Changes
Russell Glasgow
Marina McCreight
Borsika Rabin
VA HSRD/QUERI National Conference
Alexandria, VA - July 2017

2. Acknowledgment
Members of the implementation team of the Eastern Colorado Triple Aim QUERI (TAQ)*
Special thanks to Charlotte Nolan for drafting and piloting the ‘real-time’ tracking System 
*Catherine Battaglia, PI

3. Goal of Adaptation Tracking
Create an organized list of adaptations/modifications that future implementers can consider for success
Provide contextual process data to interpret outcomes (i.e., how adaptations contribute to outcomes)
Consider refinements to the recommended intervention & implementation strategies based on observed changes
To develop and test (across 3 diverse projects) a replicable, easy-to-use documentation method for recording adaptations/modifications

4. Taq overarching multi-method Assessment approach
TODAY’S FOCUS: Documenting adaptations and modifications ‘frequently’ using a tracking system integrated into the general project documentation flow (research team perspective)
Gathering data at multiple time points from delivery team members using structured interviews (implementer perspective)
Use these different approaches iteratively to complement and inform each other

5. Implementation Science and Methodological Considerations
Use a modified version of the Stirman et al Adaptation Framework influenced by the RE-AIM model and clinical experience* to create both a documentation system and interview guide
Triangulate information from two data collection methods by using information from an ongoing tracking system to further probe staff interviewees on adaptations, creating examples for interviewees based on data from our documentation system
*Hall et al. Translational Behavioral Medicine, 2017, DOI /s

6. Coding Guide: Categories and Options

7. Example

8. Examples for adaptations documented in itaq work to date
Change in recruitment materials and protocol (change in intervention)
Change in who contacts patient (task shifting)
Change in feedback procedures (implementation strategy change)
iTAQ = implementation team, Triple Aim QUERI

9. ADAPTATION TRACKING METHODS LESSONS LEARNED: STRENGTHS
Rapid and frequent assessment of modifications for QI that can quickly inform other assessment methods
Does not require clinical staff time (or minimal)
Flexible: can be based on observations, team meetings, conversations or other inputs
Can modify the coding categories or options based on results (depending on whether QI or research) to fit your project
General system has worked across three diverse projects

10. Lessons learned: Limitations
Requires in-depth knowledge of intervention and implementation strategies
(In our case) initial differentiation between intervention and implementation strategy unclear
Coding reliability not assessed thus far
Response categories need adjusting so ‘moving assessment’ and difficult to do some types of comparisons

11. What do you think?
I’m all ears

12. Coding Guide: Categories and Options

13. Adaptations Data tracking

14. Interviews: saMPLE QUESTIONS
WHAT was the nature of the change – was it a change to program content, format, delivery mode, staff delivering it, patients eligible, where, when or how it was delivered, or what?
WHO was responsible for initiating or suggesting this change? The same person(s) who initiated the change?
WHEN was this adaptation first made?
HOW or on what basis was this change made implementation challenges, time concerns, results or collected data, external or administrative concerns, patient or staff feedback, or other?