Where is the Implementation in Implementation Science? Rohit Ramaswamy January 21, 2014

From Knowing to Doing: The Gap “Our thinking about health care has to change and we have to begin to look at health care as a systems and delivery problem, not a disease problem” Dr. Jim Yong Kim, President, World Bank

What is Implementation Science? NIH Implementation science is the study of methods to promote the integration of research findings and evidence into healthcare policy and practice. Implementation Science Journal the scientific study of methods to promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice, and hence to improve the quality and effectiveness of health care. Canadian Institute of Health Research the exchange, synthesis and ethically-sound application of knowledge- within a complex system of interactions among researchers and users - to accelerate the capture of the benefits of research for [people] through improved health, more effective services and products, and a strengthened health care system

Implementation Science Steps (Bhattacharya) 1. Identify care gaps and the need for change. 2. Identify barriers to consistent use of guidelines. 3. Review evidence on implementation interventions. 4. Tailor or develop intervention to improve performance. 5. Implement intervention. 6. Evaluate the process of implementation. 7. Evaluate outcomes of the intervention (Grahamet al., 2006b).

What is Implementation ? NIH Definition: “the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings” NIRN Definition: “a specified set of activities designed to put into practice an activity or program of known dimensions”

The Implementation Research/Applied Implementation Continuum IMPLEMENTATION SCIENCE IMPLEMENTATION RESEARCH WHAT APPROACHES WORK BEST IN THE TRANSLATION OF RESEARCH TO APPLICATION ? CONTEXT SPECIFIC KNOWLEDGE ABOUT GOOD IMPLEMENTATION PRACTICE GENERALIZABLE KNOWLEDGE ABOUT APPROACHES APPLIED IMPLEMENTATION HOW SHOULD THESE APPROACHES BE ADAPTED AND APPLIED IN PARTICULAR PRACTICE CONTEXTS AND SETTINGS TO ACHIEVE SUSTAINABLE OUTCOMES ?

Applied Implementation – Key Components PROCESSES ORGANIZATIONS FACILITIES EQUIPMENT SUPPLIES IMPLEMENTATION FRAMEWORKS AND TOOLS IMPLEMENTATION SYSTEM DESIGN EVALUATION EVALUATION EVALUATION SIX SIGMA LEAN MFI CONTINUOUS QUALITY IMPROVEMENT

Designing Implementation Systems: Design Process (Brown)

Designing Implementation Systems: Design Approach

Mental Health Delivery System Design – Sehore District, Madhya Pradesh, India

Applied Implementation – Key Components PROCESSES ORGANIZATIONS FACILITIES EQUIPMENT SUPPLIES IMPLEMENTATION FRAMEWORKS AND TOOLS IMPLEMENTATION SYSTEM DESIGN EVALUATION EVALUATION EVALUATION SIX SIGMA LEAN MFI CONTINUOUS QUALITY IMPROVEMENT

Getting to Outcomes (Wandersman) #2 Goals & Objectives #3 Best Practices #4 Fit #1 Needs/ Resources/ Readiness #5 Capacities RESULTS #10 Sustain #6 Plan #7 Process Evaluation #9 Improve / CQI #8 Outcome Evaluation

NIRN Framework (Fixsen)

Implementation Example Tobacco-Cessation Strategy NIRN Framework Exploration Installation Initial Implementation Full Implementation Fixsen, Blase, Bartley, Duda, Metz, Naoom, Sims, Van Dyke, 2011

Applied Implementation – Key Components PROCESSES ORGANIZATIONS FACILITIES EQUIPMENT SUPPLIES IMPLEMENTATION FRAMEWORKS AND TOOLS IMPLEMENTATION SYSTEM DESIGN EVALUATION EVALUATION EVALUATION SIX SIGMA LEAN MFI CONTINUOUS QUALITY IMPROVEMENT

What is Quality Improvement ? Quality Improvement is a formal approach to the analysis of system performance and systematic efforts to improve it. Key words: Formal approach Analysis System performance Systematic efforts

Improving Healthcare – Quality Goals Effective Safe Equitable Patient Centered Timely Efficient

QI Methods Several methodologies developed and tested for industrial quality applications are now being used in healthcare Most popular QI methodologies: Lean Six Sigma PDSA/Model for Improvement

QI Tools: A Suite of Options

Example – Jacaranda Health Maternity Clinic – Nairobi Kenya

Example – Flow Improvement in Ghana Monitoring changes after quality improvement

Example – Flow Improvement in Wake County 74% reduction in patients turned away Reduction in wait time variability Under 1 hour: 60% 1-1.5 hours: 40% Over 1.5 hours: 0%

ONLINE GLOBAL MPH New concentration area in Applied Implementation Science Design of Implementation Systems Implementing Global Health Programs Gillings Global Implementation Laboratory Monitoring and Evaluation

Thank You!