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

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

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

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

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

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

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.”

“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)

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. http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

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

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.

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

Difficult to Change Practice and Make it Stick (Routine)

Use Implementation Science to Create Successful Change http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

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

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

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

Implementation Drivers Key elements of capacity and infrastructure that influence a program’s success http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

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%  

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; http://nirn.fpg.unc.edu/

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

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. http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

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

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. http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

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: http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

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 http://sisep.fpg.unc.edu/learning-zone/science-of-implementation/

Practices are Abandoned….

Five warning signs for De-adoption of EBPs Massatti et al., 2008

Lack of ongoing resources Massatti et al., 2008

Lack of support from external groups of the effort to change Massatti et al., 2008

Attitudes about the new practice – think we do it already versus open to learning and changing Massatti et al., 2008

Beliefs that the new practice does not fit with our knowledge/skills or the agency’s mission/philosophy Massatti et al., 2008

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

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.

Contact Heather J. Gotham, PhD Associate Research Professor Mid-America ATTC UMKC School of Nursing gothamhj@umkc.edu direct (816) 235.5058