1. Using Implementation Science to Effectively Implement Evidence-Based Practices
Heather J. Gotham, PhD
Mid-America ATTC
UMKC School of Nursing
Health Literacy: A prescription for Patient Engagement
February 12, 2013

2. what we say does not matter unless patients are able to understand
“As clinicians,
what we say does not matter
unless patients are able to understand
the 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 if
we 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 practices
Describe 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
Implementation
Incorporating 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 fields
Rural sociology
Medical sociology
Communication & marketing
Evidence-based medicine
Organizational change
Studies how evidence-based practices are used in the real world
Studies what strategies can help most efficiently implement evidence-based practices
Greenhalgh 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
Effective
Intervention
Ineffective or
Insufficient
Implementation
Inconsistent;
Not Sustainable;
Poor Outcomes X =
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 disorders
Treatment using multi-disciplinary team
Strong Implementation (High Fidelity) ACT team
Weak Implementation (Low Fidelity) ACT team
Treatment Drop-outs
15%
30%
Substance Use in Remission
55%
13%
Hospital Admissions
2.87
4.69
Here’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., 1999 10

11. The Implementation Gap in Healthcare
Patient
medication
adherence
Better
patient
health
Health
professional
adherence to
EBPs
So, 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.

12. What Works IMPLEMENTATION Effective NOT Effective
Performance Implementation(High Fidelity)
Paper Implementation
Procedure Implementation
(Low Fidelity)
Effective
INTERVENTION
NOT Effective
Copyright © Dean L. Fixsen and Karen A. Blase, 2008

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 Sponsor
Leads implementation effort, appoints the Change Agent
Acts as a mentor to maintain enthusiasm
Problem-solver, assists Change Agent and Team

16. Create a Successful Implementation Team
Change Agent
Overall responsibility for implementation and plan
Supervisory position with responsibility and authority to implement policy and programmatic changes
Recognized/respected for leadership, organizational savvy, and persistence

17. Create a Successful Implementation Team
Comprised of staff from all levels/roles
Administrative, Supervisory, Support, Technical and/or IT
Patients
Meet regularly
Review 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)
TRAINING
COMPONENTS
Knowledge
Skill
Demonstration
Use in the Classroom
Theory and Discussion
10% 5% 0%
..+Demonstration in Training
30%
20%
..+ Practice & Feedback in Training
60%
..+ Coaching in Classroom
95%

20. Must be addressed for successful implementation
Implementation Drivers
INTEGRATED & COMPENSATORY
CONSULTATION & COACHING
STAFF PERFORMANCE
EVALUATION
FACILITATIVE ADMINISTRATIVE SUPPORTS
RECRUITMENT AND SELECTION
PRESERVICE TRAINING
SYSTEMS
INTERVENTIONS
DECISION SUPPORT DATA SYSTEMS
Must be addressed for successful implementation
Implementation Research, Fixsen et al., 2005;

21. Implementation Driver
Use Implementation Drivers to
Develop an Implementation Plan
Implementation Driver
 Implementation Steps
Staff Person(s)
Deadline
Comments
Recruitment/ Staff Selection
Implementation Team
Finalize Implementation Team
Change Agent
11/11
Completed
Meet every 2 weeks through March, then re-evaluate
Team
11/18
Facil. Admin. Supports
Screening Process
What is currently done?
Are nurses already doing EMR Screening?
Change agent, head nurse
Decision Support Data Systems
EMR
Determine issues and system limits with EMR
What if only some items are completed?
Can all staff complete the screener?
Admin staff with IT staff
11/15 initial report
Review at 11/18 meeting 
Training
Targeted training needed for all levels of staff
Education for nurses on all shifts
Health coach supervisor

22. Improvement Cycles
Improvement 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 change
Study: Evaluate what happened
Act: Continue or go back to
planning

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.

25. Implementation Stages
Exploration
Assess needs
Examine
innovations
Assess fit
Promote “buy in”
Installation
Acquire resources
Create
implementation
plan
Develop
infrastructure
Prepare staff
Initial
Implementation
drivers
Manage change &
expectations
Improvement cycles
Learn from mistakes
Celebrate progress
Full
Implementation
drivers
Monitor outcomes
Improvement
cycles
Components
integrated
Fully functioning
Sustainability
From:

26. Use Implementation Science to Create Successful Change
Teams
Build an implementation team
Drivers
Training alone is never enough
Detailed implementation plan
Improvement Cycles
PDSA cycles
Stages
Implementing new practices takes months to years
Recognize the change process

27. Practices are Abandoned….

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/philosophy
Massatti et al., 2008

33. Beliefs that the new practice is neither easy to implement nor a permanent part of the agency’s services
Massatti et al., 2008

34. Sustainability
Plan for sustainability as you’re writing the grant/planning the project
Prepare for turnover
Develop expertise in the agency
What are your re-training plans?
Plan for continued resources where needed
Outcome data/continuous quality improvement
Finally, 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. Contact
Heather J. Gotham, PhD Associate Research Professor Mid-America ATTC UMKC School of Nursing direct (816)